NURS 332 Exam 3 Study Questions

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An infant is admitted to the pediatric hospital straight from the birth hospital with numerous congenital defects and a diagnosis of rule out TORCH syndrome. The father tells the pediatric nurse that he and his wife had planned a beautiful birth experience and can't believe what's happened. An appropriate nursing diagnosis for this family would be: Caregiver Role Strain, Risk for. Self-Esteem, Situational Low. Attachment, Risk for Impaired. Role Conflict, Parental.

Attachment, Risk for Impaired.

The nurse is caring for a 14-year-old female client with iron deficiency anemia. Which interventions can assist the client in obtaining normal iron levels? Select all that apply A. Assess client compliance with iron supplements. B. Apply supplemental oxygen as needed. C. Help the client pick iron-rich food choices. D. Monitor blood transfusion for signs of reactions. E. Consider starting the client on birth control. • Answer

A & C

The nurse teaches parents that absolute contraindications for pediatric immunizations include: Respiratory illness with low-grade fever. Anaphylactic reaction to previous immunization. Soreness, redness, and swelling at the previous injection site. Febrile seizure one month after the previous injection of the vaccine.

Anaphylactic reaction to previous immunization.

A child has been diagnosed with scabies. The nurse reinforces to the parents that appropriate medical therapy for this child would be: Antihistamines. Narcotic analgesics. Non-steroidal anti-inflammatory drugs (NSAIDs). Antibiotics.

Antihistamines.

Permethrin 5% (Elimite) is prescribed for a 10-year-old diagnosed with scabies. What instructions should the nurse provide for the mother? Apply the lotion liberally from head to toe. Wrap the child in a clean sheet after treatment. Leave the lotion on for 4 to 6 hours. Apply lotion only after the child has had a bath and dried thoroughly.

Apply lotion only after the child has had a bath and dried thoroughly.

14. The nurse is planning care for an 18-month-old child diagnosed with tetralogy of Fallot. Which interventions should the nurse implement to assist in managing hypercyanosis? Select all that apply. Apply oxygen. Avoid administering dopamine. Administer packed red blood cells. Use opioids to manage pain. Place child in supine position.

Apply oxygen. Administer packed red blood cells. Use opioids to manage pain.

A child has eczema. Which would be an appropriate nursing intervention to include in the care of this child? A. Applying lotrimin ointment. B. Noting distribution and type of lesions, presence of weeping, or signs of infection. C. Applying nystatin topical ointment. D. Applying silvadene cream. • Answer

A nurse is caring for an infant whose screening test reveals that he may have sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? A. Sickle solubility test (Sickledex) B. Hemoglobin electrophoresis C. Complete blood count D. Transcranial Doppler Answer

A public health nurse is preparing to teach a group of parents regarding burn prevention. The nurse knows that the group has grasped the information when a father states he will set his hot water heater at which of the following temperatures to prevent burns? A. Between 140F (60C) and 150f (65.6C) B. Less than 120f (48.9C) C. Between 130F (54.4C) and 140F (60C) D. Between 120F(48.9C) and 130F (54.4C) • Answer

Following the administration of the hepatitis B vaccination to a child, which symptoms would indicate an allergic reaction? A. Redness or warmth at the injection site B. Onset of wheezing C. Pain at the injection site D. Temperature increase to 99.2degrees F (37.3degrees C) • Answer

8. The nurse is gathering the history on a child newly diagnosed with Wilms tumor. The nurse should be aware of which common symptom reported with Wilms tumor? a. Hypotension b. A firm mass in the abdomen c. Proteinuria d. Chest pain i. Answer

B •

Four-year-old Tyler James has been diagnosed with disseminated intravascular coagulation (DIC). He is not in shock. Which of the following would most likely be part of your treatment plan for him? A. Preparing him for a splenectomy B. Treatment of underlying cause C. Intravenous immune globulin (IVIG) D. Applying ice to affected areas • Answer

B •

Fourteen-year-old Tory Kendrick is in the hospital to be treated for a sickle cell disorder crisis. His symptoms are pain and dehydration. What interventions should you take immediately? A. A transfusion B. Intravenous opioids and saline fluid boluses C. Pneumococcal immunization D. Heat packs and warm blankets • Answer

B •

The nurse identifies which classes of medications as being part of highly active antiretroviral therapy (HAART) for HIV? (Select all that apply) A. Anti-infectives B. Nucleoside reverse transcriptase inhibitors (NRTIs) C. Protease inhibitors D. Biologic response modifiers E. IV immune globulins (IVIG) • Answer

B & C

A nurse is caring for a 2-yr-old child who is cyanotic and is in the hospital for a cardiac catheterization to repair cardiac defects. The child will be transferred to the pediatric ICU following the procedure. Which of the following is an appropriate nursing action when providing care to this child? A. Place on NPO status for 12 hr prior to procedure B. Check for iodine or shellfish allergies prior to procedure C. Elevate the affected extremity following the procedure D. Limit fluid intake following the procedure • Answer

B. Iodine-based dye may be used.

Which evaluation would indicate a toxic dose of digoxin? Tachycardia and dysrhythmia. Headache and diarrhea. Bradycardia and nausea and vomiting. Tinnitus and nuchal rigidity.

Bradycardia and nausea and vomiting.

A 10-year-old sustained partial thickness burns to his right arm and abdomen after tossing gasoline on a fire. What would the nurse expect the appearance of the burn site to be? Smooth and bright red. Bright red with numerous blisters. White and waxy. Dark brown and firm.

Bright red with numerous blisters

A 4-year-old child with infective endocarditis will be discharged in 2 days. When completing the discharge plan, which should the nurse include? A. How to obtain blood cultures B. The need for future surgery C. The use of prophylactic antibiotics D. How to monitor blood pressure daily • Answer

A 7-year-old child has experienced no heart effects from an episode of rheumatic fever. When discussing secondary prophylaxis with the child's parents, how long would the nurse tell them that this would be required? A. Until the child is 12 years old B. Until the child is 10 years old C. Until the child is 21 years old D. This will be a lifelong requirement • Answer

A child has been diagnosed with scabies. The mother asks what she can do to get rid of scabies in the home. What should the nurse advise the mother to do? A. Discard all bedding and stuffed animals that cannot be washed in hot soapy water and dried in the dryer for at least 20 min. B. Use flea-killing carpet powder on all carpets and rugs. C. Seal nonwashable items in plastic bags for 2 weeks. D. Store bedding in a tightly sealed bag for 5 days, then wash. • Answer

A child with suspected acute lymphoblastic leukemia (ALL) complains of severe pain, pointing to the middle of her thigh and limping with ambulation. The mother asks the nurse about the origin of the pain. Which response by the nurse best describes the likely origin of the pain and limp? a. "The pain is likely caused by an infection in the bone." b. "The pain is likely caused by lack of blood-producing cells in the bone marrow." c. "The pain is likely caused by crowding of the marrow by ineffective blood-producing cells." d. "The pain is likely muscle pain due to lack of exercise last week." i. Answer

A client received methotrexate 10 days ago as part of the induction phase of treatment for acute lymphoblastic leukemia (ALL). The client vomits dark bilious fluid several times. What should the nurse's first action be? a. Draw blood for a CBC with differential. b. Medicate with anti-nausea medication. c. Initiate NPO orders. d. Call the health care provider to report emesis. i. Answer

A health care provider finds a swollen testicle in a male client suspected to have acute lymphoblastic leukemia (ALL). For what treatment does the nurse prepare the client and family? a. Chemotherapy injected into the testicle b. Removal of the testicle c. Radiation to the testicle d. Intrathecal chemotherapy administration i. Answer

A nurse is caring for a child who is postop following surgical removal of a Wilms' tumor. Which of the following assessments is an indication to continue NPO status? a. Abdominal girth 1 cm larger than yesterday b. Report of pain at operative site c. Absent bowel sounds d. Passing flatus q 30 min i. Answer

A nurse is caring for a client who has a moderate burn. Which of the following is an appropriate action for the nurse to take? A. Maintain immobilization of the affected area B. Expose affected areas to the air C. Initiate a high-protein, high-calorie diet D. Implement contact isolation • Answer

A student nurse is asking a nurse about a medication administered to children that increases the contractility of the myocardium and stimulates both adrenergic and dopaminergic receptors. What medication should the nurse educate the student about? A. Digoxin B. Isoproterenol C. Dopamine D. Milrinone • Answer

Callie Lozano has been diagnosed with a thalassemia. Which is an important part of her nutritional plan? A. Add iron-rich foods. B. Restrict foods with vitamin C. C. Supplement with folic acid. D. Limit cow milk to 18 to 24 oz per day. • Answer

Five-year-old Kaila Kent has been diagnosed with Wilms tumor. Which of the following is a possible treatment option? a. Monitoring BUN and creatinine levels b. Intravenous pyelogram c. Removal of the affected kidney d. Tissue typing i. Answer

Nursing assessment of a school-age child reveals inflamed joints, rash on the trunk, and aimless movements of the extremities. The nurse recognizes these findings as characteristic of which acquired cardiac disease? A. Infective endocarditis B. Valvular insufficiency C. Rheumatic fever D. Kawasaki disease • Answer

The mother of a 5-year-old child preparing for diagnostic testing for Wilms tumor asks the nurse why the health care provider wants to do a CT scan of her child's liver and spleen. What is the best response by the nurse? a. "This will tell us if the tumor can be removed." b. "To determine what to do next." c. "To check for any possible metastasis." d. This is the correct answer. e. "To see if those organs are functioning." i. Answer

The mother of a client with newly diagnosed acute lymphoblastic leukemia (ALL) asks the nurse about the cause of the disease. What is the nurse's best response? a. "ALL is caused by exposure to the sun." b. "Mothers receiving ionizing radiation prior to pregnancy have children with an increased risk of acquiring ALL." c. "There is some association between exposure to infectious agents and genetic alterations such as trisomy 21." d. "ALL in children is caused by poor eating habits and lifestyle choices." i. Answer

The nurse is caring for a 9-year-old client diagnosed with thalassemia. The nurse recognizes which findings on assessment as a distinctive sign of this specific disorder? A. Headache B. Fatigue C. Bronzed skin D. Restlessness • Answer

• When planning the care for a child admitted with a fever and rash that is suspected to be measles, what will the nurse incorporate in the plan of care? A. Giving the child a toy to use to scratch the rash to prevent secondary infection B. Instructing the parents to administer aspirin for fever C. Dedicated equipment such as blood pressure cuffs and stethoscopes D. Telling the child she must drink from a graduated cylinder to obtain the most accurate intake measurement • Answer

A 7-year-old client is diagnosed with rheumatic fever. The physician orders throat cultures of all family members. The nurse explains that: "Family members can carry streptococcus and be asymptomatic." "The child must have infected others." "Rheumatic fever is familial." "Family members can carry the virus for rheumatic fever."

"Family members can carry streptococcus and be asymptomatic."

An infant born to a mother known to be infected with HIV+ has also been diagnosed with HIV+. While assessing the psychosocial support for the family, the nurse should ask: "Does the family belong to a support group?" "Are there neighbors near by?" "What type of insurance does the family have?" "Does mother have a car?"

"Does the family belong to a support group?"

Intravenous morphine is ordered for a 13-year-old hospitalized with major burns to 30 percent of his body. What is the rationale for IV morphine? Longer half-life. Predictable absorption rate. Prevents ileus. Fewest side effects.

Predictable absorption rate.

The nurse identifies which classes of medications as being part of highly active antiretroviral therapy (HAART) for HIV? Select all that apply. Protease inhibitors Biologic response modifiers IV immune globulins (IVIG) Nucleoside reverse transcriptase inhibitors (NRTIs) Anti-infectives

Protease inhibitors Nucleoside reverse transcriptase inhibitors (NRTIs)

A child with leukemia has developed pancytopenia. Measures designed to reduce stomatitis in this child while receiving chemotherapy would include: Alcohol-based mouthwash to reduce oral organisms. Brushing the teeth twice a day with a firm-bristled toothbrush. Increasing intake of citrus juices, such as orange juice, that contain vitamin C. Rinsing the mouth several times a day with plain water.

Rinsing the mouth several times a day with plain water.

The nurse is teaching a class on newborn care to a group of expectant parents. In explaining why the parents need to protect the infant from heat loss, the nurse should explain that the characteristic of the infant's skin that is responsible for heat loss is: Lanugo. Nonfunctioning sebaceous glands. Nonfunctioning apocrine glands. Thinner skin.

Thinner skin.

How is prostaglandin E1 used in the treatment of cardiac defects? To repair the ductus arteriosus To lessen the effects of apnea To help treat systemic vasodilation To keep an infant partially oxygenated

To keep an infant partially oxygenated

A child is being seen in the ambulatory clinic for a sore throat diagnosed as caused by group A beta hemolytic streptococcus. The nurse provides care with the understanding that the risk of developing rheumatic fever is greatest Two weeks later. Prior to the administration of an antibiotic. Once the child has begun antibiotic therapy. With the onset of the strep infection.

Two weeks later.

6. The nurse is caring for a 5-year-old child following cardiac catheterization for repair of an atrial septal defect. Which intervention should the nurse implement? Observe for signs of decreased perfusion. Restrict oral fluids. Keep on bed rest for 2 hours. Maintain quiet, low exertion activity for 12 hours.

Observe for signs of decreased perfusion.

When assessing a child with a possible diagnosis of facial cellulitis, the nurse will want to question the parent about a recent history of: Otitis media. Cat scratch. Sunburn. Sinusitis.

Otitis media.

Which are interventions for hypercyanosis? Select all that apply. Packed red blood cells Frequent small feedings Intravenous fluids as needed Observe for signs of bleeding Knee-chest position

Packed red blood cells Intravenous fluids as needed Knee-chest position

A 13-year-old child is scheduled for a bone marrow transplant. The nurse has explained the procedure to the patient and his mother. Which statement by the mother indicates a need for additional teaching? "How long will it take my child to wake up from the anesthesia?" "I can't believe they will take the sample out of his hip." "He will need to be watched for bleeding and infection after the procedure." "The doctors are going to use this test to find out why he can't fight infections."

"How long will it take my child to wake up from the anesthesia?"

The nurse is caring for a child in the ICU being treated for DIC. Which of the following lab tests will take priority in order to monitor the efficacy of the heparin therapy? Hemoglobin and Hematocrit. Platelets. Bilirubin levels. Partial prothrombin time (PTT).

Partial prothrombin time (PTT).

9. The nurse is explaining to a student nurse that left-to-right shunting of blood in the heart can lead to pulmonary overload and congestive heart failure. Which heart defect could the nurse use as an example in her explanation? Tetralogy of Fallot Pulmonic stenosis Coarctation of the aorta Patent ductus arteriosus

Patent ductus arteriosus

The nurse is caring for a child with infective endocarditis. Which intervention would be most effective for the treatment of this disease process? A. Administer ordered antibiotics. B. Administer pain medication. C. Administer ordered anticoagulant. D. Strictly manage intake and output. • Answer

When assessing an 18-year-old client with disseminated intravascular coagulation (DIC), which assessment data would the nurse immediately report to the health care provider? Select all that apply A. Capillary refill of 5 sec B. Heart rate of 180 beats/min C. Blood pressure of 68/32 mmHg D. Family states, "I'm scared she will die from this." E. Urine output that was pink tinged, but is now yellow • Answer

A, B, C

The nurse is caring for an adolescent client with severe acne. Identify potential nursing diagnoses appropriate for this client. (Select all that apply) A. Disturbed Body Image B. Deficient Knowledge related to outbreak prevention C. Self-care Deficit Bathing and Hygiene D. Risk for Infection E. Self-mutilation • Answer

A, B, C, & D

A client is diagnosed with rheumatic fever and receiving salicylate therapy. Which evaluation would indicate a therapeutic response to this treatment? Alleviation of chorea. Increase in red blood cell count. Decrease in blood pressure. Alleviation of elevated temperature and arthralgia.

Alleviation of elevated temperature and arthralgia.

The mother of a child receiving chemotherapy asks the nurse why they are giving the child more than one drug at a time. The mother states this is why her child is so sick and it would be better to give the series one drug at a time. The nurse explains to the mother that using protocols of combination drugs: Allow for a better kill of cancer cells. Prevents renal damage. Helps the child to get over the nausea faster. Is a more efficient use of the nurse's time.

Allow for a better kill of cancer cells.

After a pediatric client has a cardiac catheterization, which intervention would have the highest priority in the immediate postoperative period? Encourage intake of small amounts of fluid. Teach the parents signs of congestive heart failure. Monitor the site for signs of infection. Apply direct pressure to entry site for 15 minutes.

Apply direct pressure to entry site for 15 minutes.

An 8-year-old is being admitted in vaso-occlusive crisis. When the care plan is being created, which of the following nursing actions should be given priority? Administering high concentration of oxygen in order to provide adequate oxygenation. Evaluating the acid-base status and administering sodium bicarbonate as necessary. Assessing pain and administering pain medication as necessary. Factor VIII replacement.

Assessing pain and administering pain medication as necessary.

A child has been burned and is brought to the emergency department (ED). Initial assessment shows that the child's face and the hair in the nares are singed. The pulse is elevated, and breathing is rapid. What is the nurse's first concern? A. Circulation B. Airway maintenance C. Removal of the child's clothing D. Fluid replacement • Answer

A child has sustained a severe burn to the face. All of the following have been ordered for this child. Which intervention will the nurse initiate first? A. Start intravenous (IV) fluid. B. Establish an airway. C. Provide relief of pain. D. Place a Foley catheter. • Answer

A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an appropriate action for the nurse to take? A. Administer an IV infusion of 0.9% sodium chloride B. Apply cool, wet compress to the affected area C. Clean the affected area using a soft-bristle brush D. Administer morphine sulfate • Answer

The nurse is caring for a 5-year-old child following cardiac catheterization for repair of an atrial septal defect. Which intervention should the nurse implement? A. Keep on bed rest for 2 hours. B. Observe for signs of decreased perfusion. C. Maintain quiet, low exertion activity for 12 hours. D. Restrict oral fluids. • Answer

The nurse is caring for an 8-year-old client with beta-thalassemia major. When doing discharge teaching, the nurse should provide which information for the caregivers? A. Encourage iron-rich foods. B. Maintain regular evaluations of hemoglobin levels. C. Avoid folic acid supplements. D. Deferoxamine will turn the urine orange in color. • Answer

The nurse is preparing to discharge a pediatric patient from a burn unit. After discharge teaching, the nurse knows that the family has understood when they state they should change the batteries in their smoke detectors at which intervals? A. Every 2 years B. Every year C. Every 30 days D. Every 6 months • Answer

The nurse is preparing to discharge a school-age child who was diagnosed with heart failure. What diuretic, which will assist in decreasing cardiac preload, should the nurse educate the family about? A. Furosemide (Lasix) B. Hydrochlorothiazide (Esidrix, Microzide) C. Bumetanide (Bumex) D. Spironolactone (Aldactone) • Answer

The nurse is providing health promotion education to the parents of an 18-month-old child with a history of atrial septal defect. Which information should be included in this parent education? A. Begin routine dental visits at 4 years of age. B. Receiving an influenza vaccine annually is important. C. Avoid live virus vaccines if scheduled for surgery 4 to 6 months from vaccine date. D. Oral care should be provided when remembered. • Answer

The parent of a child undergoing chemotherapy for Wilms tumor asks the nurse why the child must wear a mask when in public places. Which response by the nurse is most appropriate? a. "Chemotherapy makes the oral mucous membranes deteriorate and makes them susceptible to infection." b. "Chemotherapy decreases immune system function, increasing the risk of acquiring an infection." c. This is the correct answer. d. "Chemotherapy kills cancer cells, and your child might spread those cells to others." e. "The mask will hide the effects of the chemotherapy." i. Answer

A child has been diagnosed with eczema. The nurse will observe for what lesions associated with this disorder? (Select all that apply) A. Crusts B. Thickening and darkening of the skin C. Comedones D. Xerosis E. Burrows • Answer

B & D •

A nurse is caring for an infant who has diaper dermatitis. Which of the following should be included in the plan of care (select all that apply)? A. Apply talcum powder with every diaper change B. Allow the buttocks to air dry C. Use commercial baby wipes to cleanse the area D. Use cloth diapers until rash is gone E. Apply zinc oxide ointment to the affected area • Answer

B & E.

The nurse is caring for a child with a recent diagnosis of infective endocarditis. The child's mother appears very upset and asks the nurse what can be done to help her son. Which would be the best response by the nurse? A. "Aspirin will be given to help thin out his blood." B. "He will need surgery to repair the damage to his heart." C. "High-dose antibiotics will help kill the bacteria that are causing the problem." D. "High blood pressure medications will prevent any additional complications." • Answer

The nurse is documenting the assessment of a child with rheumatic fever. Which assessment finding would the nurse be most concerned about? A. Chorea B. Mild fever C. Heart murmur D. Skin rash • Answer

The nurse is educating the mother of an infant with heart failure about ways to maximize the infant's nutrition by preventing overexertion. What information should the nurse include? A. Position infant in a supine position. B. Allow infant to cry before feeding. C. Provide periods of uninterrupted rest between feedings. D. Burp infant only after feeding. • Answer

The nurse caring for a client who has disseminated intravascular coagulation (DIC) secondary to sepsis identifies which treatments as priorities? (Select all that apply) A. Fluid restriction for volume overload B. Administration of desmopressin (DDAVP) C. Administration of antibiotics D. Administration of fresh frozen plasma E. Administration of heparin for anticoagulation • Answer

C, D, & E

The nurse is caring for a 17-year-old client with mild iron deficiency anemia. Which interventions would be appropriate? (Select all that apply) A. Give a transfusion of packed red blood cells. B. Supplement iron with intramuscular injections. C. Limit cow milk in diet. D. Encourage meats, fish, and poultry in diet. E. Encourage dried fruits in diet. • Answer

C, D, & E

A client with acute lymphoblastic leukemia (ALL) is experiencing stomatitis following chemotherapy administration. Which interventions would the nurse educate the child and family about to help with stomatitis? Select all that apply. a. Utilize firm brushes for oral care. b. Use alcohol-based mouth rinses. c. Watch for secondary infections in the mouth. d. Utilize pain medication for painful swallowing. e. Avoid spicy foods. i. Answer

C, D, E

A nurse is caring for a child who has oral mucositis. Which of the following is an appropriate action for the nurse to take? Select all that apply a. Swab the mucosa with lemon glycerine swabs b. Apply viscous lidocaine c. Offer soft foods d. Use a soft, disposable toothbrush for oral care e. Encourage gargling with a warm saline mouthwash i. Answer

C, D, E

A mother known to be infected with HIV gives birth to a healthy-appearing male infant. Which plan is best to follow-up on the infant's HIV status? CD4+ counts q 3 months until 2 years old. p24 antigen test one time. White blood cell counts every 4 weeks. ELISA for initial test.

CD4+ counts q 3 months until 2 years old.

A 2-year-old child in the hospital for a fractured femur breaks out with chickenpox. Which nursing intervention will best prevent secondary skin infections? Caladryl lotion to lesions. Acetylsalicylic acid gr. X. I.V.I.G. for first 3 days. Nubaine every 4 hours as needed for pain.

Caladryl lotion to lesions.

A toddler has been diagnosed with an acyanotic cardiac defect. Which assessment data would most likely indicate congestive heart failure? Heart murmur. Cardiac volume overload. Anuria. Excitability.

Cardiac volume overload.

The nurse is educating a women's community group about congenital heart disorders. What factor should the nurse identify as placing a child at a greater risk for being born with a congenital heart disorder? Mother infected with gonorrhea Young age of mother Chromosomal abnormality such as Down syndrome Fetal exposure to a bacterial infection

Chromosomal abnormality such as Down syndrome

Which of the following is an accurate description of disseminated intravascular coagulation? A. A condition resulting from an autoimmune reaction in the child's body B. A condition resulting from a dysfunction in clotting factor vWF C. A hereditary blood clotting disorder caused by an autosomal recessive gene D. A condition that causes a child to bleed excessively at the same time that the blood is trying to clot • Answer

An 8-year-old child in the burn unit refuses to eat anything on the meal tray. What intervention by the nurse is most helpful? A. Allow the child to make food selections. B. Allow the child to go to the playroom only if the child eats 75% of each meal. C. Encourage the child to eat, or a nasogastric (NG) tube may have to be inserted. D. Serve large meals to give the child many food choices. • Answer

An adolescent receiving treatment for acute lymphoblastic leukemia (ALL) cries and tells the nurse she is afraid to see her friends because she is losing her hair. The nurse questions the client and determines the adolescent has not considered suicide. The nurse institutes interventions for which nursing diagnosis? a. Body image disturbance b. Altered nutrition c. Altered growth and development d. High risk for injury to self i. Answer

The nurse is assessing vaccination records of several clients. Which records indicate that a client is up-to-date on immunizations? A. An 18-month-old who has received three hepatitis B; three rotavirus; four diphtheria, tetanus, pertussis (DTaP); four Hib; four pneumococcal; three inactivated poliovirus; one measles, mumps, and rubella (MMR); one varicella; one hepatitis A; and one influenza B. A 2-week-old who has not received any vaccinations C. A 7-month-old who has received two hepatitis B; three rotavirus; three diphtheria, tetanus, pertussis (DTaP); three pneumococcal, and two inactivated poliovirus D. A 12-week-old who has received one hepatitis B • Answer

A child is in the clinic for a prick test. Because of the risk of anaphylaxis, the nurse has available for emergency treatment: Epinephrine. Corticosteroids. Narcan. Cromolyn sodium.

Epinephrine.

A 2-year-old child is being discharged home and will have palliative surgery for tetralogy of Fallot at a later date. The mother wants to know about how much physical activity she can allow for the child. The nurse's best answer is: "Allow the child to regulate her activity." "Keep her on complete bedrest." "Limit her activities to a few hours." "Keep the child from crying."

"Allow the child to regulate her activity."

The nurse has explained allergy-proofing the home to the mother of a child with dust allergies. Which statement by the mother indicates a clear understanding of appropriate allergy proofing? "I'm going to replace the cotton curtains on the window with blinds." "The only toys allowed in his bedroom are his stuffed toys." "I should store his out-of-season clothes in his bedroom." "The mattress and box springs both need to be enclosed in a thick plastic cover."

"The mattress and box springs both need to be enclosed in a thick plastic cover."

Four-year-old Timothy Tanaka has been diagnosed with Kawasaki disease. Which of the following should be an intervention in your plan of care? A. Oral hygiene to keep mouth moist B. Prophylaxis with antibiotics C. Soda pop or lemonade for hydration D. Warm compresses as tolerated • Answer

A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following clinical manifestations support this diagnosis? (Select all that apply) o Erythema marginatum (rash) o Continuous joint pain of the digits o Tender, subcutaneous nodules o Decreased erythrocyte sedimentation rate (ESR) o Elevated c-reactive protein (CRP) • Answer

A & E

A nurse is assessing an infant who has eczema. Which of the following are clinical manifestations of eczema in an infant? (Select all that apply) o Generalized distribution o Papules o Clusters o Crusting lesions o Lichenification • Answer

A, B, & D

Which assessment data would the nurse identify as indicating an opportunistic infection in the child with HIV? (Select all that apply) A. Cough, night sweats, and weight loss B. Joint pain and swelling C. White coating on the tongue that will not scrape off D. Temperature of 100.8 degrees F (38.2degrees C) E. A rash across the bridge of the nose and cheeks • Answer

A, C & D

An instructor is teaching an orientation class for new burn center nurses. What types of major burns can the nurses expect to see? (Select all that apply) A. Superficial burns involving the upper portion of the back B. Full thickness burns covering greater than 5% of the body surface area C. Burns involving major joints D. Inhalation burns E. Partial thickness burns that cover 5% of the body surface area (BSA) • Answer

B, C, & D

The nurse is admitting several children who have skin conditions to the hospital unit during the work shift. The child who does not pose a risk for spread of their disease is the child with: Scabies. Impetigo. Eczema. Pediculosis capitis.

Eczema.

The nurse prepares the second diphtheria, tetanus toxoid, and acellular pertussis (DTAP) and second inactivated polio vaccine (IPV) immunization injections for an infant who is 4-months-old. Provided a separate injection site is used for all injections, the nurse also may give which of the following immunizations during the same well child care appointment? Varicella (Var). Influenza (TIV). Measles, mumps, rubella (MMR). Haemophilus influenzae type B (HIB).

Haemophilus influenzae type B (HIB).

A child with leukemia develops oral stomatitis secondary to chemotherapy treatments. Nursing assessments related to this condition should focus on: Hydration status. Vitamin C intake. Condition of teeth. Handwashing techniques.

Hydration status

In teaching a group of school children, a nurse would explain that lice on a child can be most easily spread by: Sitting close to someone who had lice. Sharing hats at recess. Riding in the same car. Riding on the same bus.

Sharing hats at recess.

The nurse has admitted a 2-year-old in vaso-occlusive crisis. As the nurse starts the initial assessment, the child insists upon lying in bed, on her side with her knees flexed to the abdomen. The nurse would want to further assess the child for the presence of: Stomach pain. Nausea. Constipation. Fear secondary to the impact of hospitalization.

Stomach pain.

A child is being discharged from the nursery with a positive TORCH titer. Parents should be informed that: The child may shed the virus for a year. TORCH is a genetic disorder. No follow-up is necessary. Medication will not be needed for this condition.

The child may shed the virus for a year

A school-age child is being admitted for surgical removal of a brain tumor. Expected nursing assessments during the preoperative period would include: Bulging fontanels. Vomiting. Elevated blood glucose levels. Drainage from the ear or nose.

Vomiting.

An infant with AIDS will be attending daycare. The daycare workers are concerned about spreading the virus. The public health nurse is explaining to the workers the precautions they should take. These precautions include: Storing all of this infant's supplies separately from the other children. Wearing gloves when changing the child's diapers. Always wearing gloves and isolation gowns when handling the infant. Minimizing contact with the infant when it is febrile.

Wearing gloves when changing the child's diapers.

Which assessment data would the nurse identify as indicating an opportunistic infection in the child with HIV? Select all that apply. Cough, night sweats, and weight loss Temperature of 100.8degrees F (38.2degrees C) Joint pain and swelling A rash across the bridge of the nose and cheeks White coating on the tongue that will not scrape off

Cough, night sweats, and weight loss Temperature of 100.8degrees F (38.2degrees C) White coating on the tongue that will not scrape off

A toddler is being discharged from the hospital diagnosed with allergies. The child is on corticosteriods and prophylactic antibiotics. Which statement from the mother suggests understanding of the child's allergic reaction? "I will clean the baby's room with sterile water." "I will cover the wood floor with carpeting for easier cleaning." "The dog shouldn't be allowed outside because it will pick up pollens in its coat." "I will insist that no one smoke in the house."

"I will insist that no one smoke in the house."

A young infant is diagnosed with severe combined immunodeficiency disorder (SCID). The mother tells the nurse that she is unclear about the nature of the disease. Which statement would give the nurse the most cause for concern about the mother's level of knowledge? "My child will grow out of this." "Bone marrow transplantation may be possible." "The prognosis for this disease is not good." "My child contracted the disease because of me."

"My child will grow out of this."

A 2-year-old child has just been diagnosed with sickle cell anemia. The nurse has explained the diagnosis to the family as well as provided information about the treatment plan. The nurse will anticipate the need for additional teaching when the mother makes the statement: "My husband loves to fly his small plane. I guess we'll have to take a commercial plane for our trips from now on." "If my child gets the flu bug, she might develop a sickling crisis." "My child will need extra iron tablets because of her anemia." "During a sickling crisis, my child will probably be hospitalized for pain control and hydration therapy."

"My child will need extra iron tablets because of her anemia."

The nurse in the pediatrician's office receives a call from the mother of a child who was started on iron supplements approximately 2 weeks ago. The mother is panicked because this morning her daughter's stools were a green, tarry color. The nursing response would be: "This is an expected symptom of the iron deficiency anemia." "This is a normal sign that the iron preparation is working properly." "This is a sign that the dose of iron is more than required." "This is a sign that the child is experiencing bleeding and needs to come to the office immediately."

"This is a normal sign that the iron preparation is working properly."

A 2-year-old with hemophilia is being discharged, and the nurse is completing discharge teaching with his parents. Which of the following statements by the parents indicates they require further teaching regarding hemophilia? "It is good to know that his sister will not get hemophilia also." "If our son has a temperature, we will not give aspirin or ibuprofen, only acetaminophen." "We will get a Medic-AlertTM bracelet for our son as soon as we get home." "We will be sure to watch our son very closely to make sure he does not have another episode of bleeding."

"We will be sure to watch our son very closely to make sure he does not have another episode of bleeding."

A newborn diagnosed with hypoplastic left heart syndrome is scheduled for a heart transplant. The nurse informs the mother that the transplanted heart usually lasts for how long before another transplant is needed? 5 to 9 years 16 to 20 years 10 to 15 years 0 to 4 years

10 to 15 years

A child is being admitted to the unit with thalassemia major. In preparing patient assignments, the charge nurse would want to assign a nurse to this child who can: Teach dietary sources of iron. Administer blood transfusions. Work with a dying child. Monitor the child for bleeding tendencies.

Administer blood transfusions.

A 5-year-old was brought to the emergency room after being burned trying to put out a fire that started in his closet where he was playing with matches. What should be the priority nursing assessment? Level of pain. Airway patency. Psychosocial needs. Signs of infection.

Airway patency.

An adolescent has been diagnosed with acne. What various treatment options will the nurse explain? (Select all that apply) A. Benzoyl peroxide B. Topical antibacterials C. Topical steroids D. Ultraviolet B phototherapy E. Topical retinoids • Answer

A, B, & E

A child is being seen in ambulatory clinic for vague symptoms. A CBC with differential is drawn. The nurse notes that the basophil count on the CBC is elevated. The nurse recognizes this indicates the problem is probably: Allergic in nature. Viral-based. Bacterial in nature. A chronic condition.

A chronic condition.

It is most important to check the pedal pulses in a child with which of the following burn injuries? A third-degree burn to the medial aspect of the left thigh. A third-degree burn to the posterior of the right leg. A circumferential burn to the upper half of the right lower leg. Second and third-degree burns to the upper thigh of the left leg.

A circumferential burn to the upper half of the right lower leg.

20. Ten-month-old Chandra Sunil is the child of recent immigrants to the United States. Chandra has never been examined by a doctor or received any medical care until now. She exhibits symptoms of poor feeding and failure to thrive, and she has a loud murmur and clubbing of fingers and toes. What type of defect do you suspect she has? A defect causing increased pulmonary bloodflow A defect causing obstructed systemic bloodflow A defect causing decreased pulmonary bloodflow A defect causing club foot

A defect causing decreased pulmonary bloodflow

A client is being admitted for mild neutropenia and a severe oral monilial infection. The nurse should assign the child to which room? A semi-private room with a medical client. A semi-private room with a surgical client. A private room without further precautions. A private room with protective isolation.

A private room without further precautions.

Which statements indicate that the nurse is providing family-centered care to the child with disseminated intravascular coagulation (DIC) and his family? (Select all that apply) A. "Would you like to take your child's temperature?" B. "When we draw your child's blood, we are looking to see how long it takes to clot." C. "Do you have any religious beliefs or spiritual practices you would like me to be aware of?" D. "You can stay here with your child as long as you would like." E. "When I come in to do your child's assessment, I will need you to leave so that I can concentrate." • Answer

A, B, C, & D •

When assessing a client, the nurse would recognize which symptoms as clinical manifestations of thrombocytopenia? Select all that apply A. Frequent episodes of epistaxis B. Small pinpoint red or purple spots on the skin C. Bleeding gums after the client brushes teeth D. Frequent sneezing E. Occult or frank blood in stools • Answer

A, B, C, & E

The nurse is teaching a group of adolescents about care for acne vulgaris. What points should be included in this teaching session? (Select all that apply) A. Wash skin with mild soap and water twice a day. B. Use astringents and vigorous scrubbing. C. Avoid picking or squeezing the lesions. D. Avoid sun exposure if on tetracycline. E. Use petroleum-based hair products. • Answer

A, C, & D

A nurse is caring for a child who is receiving chemotherapy. Which of the following are clinical manifestations of neuropathy? SATA a. Constipation b. Skin breakdown c. Foot drop d. Jaw pain e. Hemorrhage cystitis i. Answer

A, C, D

A school-age child is admitted with a suspected acyanotic heart disease. After learning that the heart defect is a congenital disorder, the parents ask the nurse how they could have missed the problem all these years. The nurse's response should include the information that: Acyanotic heart disease may be asymptomatic. The child would only be cyanotic with great exertion. The parents should have recognized the symptoms associated with an acyanotic heart defect. The parents were probably ignoring the symptoms and hoping they would go away.

Acyanotic heart disease may be asymptomatic.

Which are criteria for antibiotic prophylaxis for bacterial endocarditis? (Select all that apply) A. No previous exposure to endocarditis B. Prosthetic valve C. Transplant patients who develop valvulopathy D. Unrepaired congenital heart disorder E. Allergy to antibiotics • Answer

B, C, & D •

Which are parts of discharge care and teaching for Kawasaki disease? Select all that apply A. Patients should not be given aspirin, because of the danger of Reye syndrome. B. Fever may recur and if it does, treatment should be sought. C. For children who have received IVIG, any immunization for live virus vaccines should be postponed for at least 11 months. D. Clients might need medical care for head injuries that would be minor in other children. E. Children should not play sports and should avoid physical exertion. • Answer

B, C, & D •

A nurse is assessing an infant who has scabies. Which of the following are expected findings? (Select all that apply) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Bluish-gray skin color E. Pimples on the trunk • Answer

B, C, & E

A client diagnosed with acute lymphoblastic leukemia (ALL) with cranial nerve involvement is scheduled to receive a 5-day course of radiation to the face. The nurse is planning care for the client. Which items will be included on the problem list? Select all that apply. a. Constipation b. Fear related to treatment regimen c. Altered nutrition d. Altered skin integrity e. Potential altered self-image i. Answer

B, C, D, E

A nurse is assessing a child who has leukemia. Which of the following are early clinical manifestations of leukemia? SATA a. Hematuria b. Anorexia c. Petechiae d. Ulcerations in the mouth e. Unsteady gait i. Answer

B, C, E

The nurse is caring for a school-age child experiencing edema and diaphoresis secondary to heart failure. Which nursing interventions should the nurse implement to prevent skin breakdown? Select all that apply. A. Encourage child to change position every 4 hr. B. Apply moisture barrier to skin. C. Pad bony prominences. D. Avoid elevating extremities E. Use gentle soap with no perfumes. • Answer

B, C, E

A nurse is assessing an infant. Which of the following should the nurse recognize s clinical manifestations of heart failure? (Select all that apply) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring • Answer

B, D, & E

A nurse is planning care for an infant who has been prescribed a lumbar puncture. Which of the following is an appropriate action for the nurse to take? a. Cleanse the thoracic area of the infant's back with an antiseptic solution b. Apply a eutectic mixture of local anesthetics (EMLA) cream just before the procedure begins c. Restrain the infant during the procedure to prevent movement d. Position the infant with his head extended and chin raised i. Answer

A child with sickle cell anemia is admitted to the hospital. The nurse anticipates that laboratory evaluation of the client's red blood cells would reveal which of the following? Polycythemia. Hematopoiesis. Crescent-shaped red blood cells. Hypochromatic red blood cells

Crescent-shaped red blood cells.

A child has been diagnosed with tetralogy of Fallot and is taking Prostaglandin 1 (Alprostadil). The child is very cyanotic, weak, and has moist respirations. Which evaluation would indicate a therapeutic response to this drug? Cyanosis does not increase. Blood pressure lowers. Respirations increase. Temperature drops.

Cyanosis does not increase.

7. A child is diagnosed with Wilms tumor. In planning care, what key point should the nurse emphasize to the parents? a. Unlimited visits from friends and family will improve the child's morale. b. Encourage the child to remain active. c. The child will need surgery only; chemotherapy and/or radiation are contraindicated. d. Do not put pressure on the abdomen. i. Answer

A child newly diagnosed with acute lymphoblastic leukemia (ALL) is going to be receiving chemotherapy. While performing teaching, the nurse should include that the most common side effects of this treatment affect what body system? a. Respiratory b. Cardiovascular c. Neurological d. Gastrointestinal i. Answer

Which are examples of best practices related to vaccinations? (Select all that apply) Documenting as follows A. Notifying the parents that all vaccinations must be given intramuscularly B. 02/27/2012. Administered hepatitis B vaccine, lot # 182 exp 12/2015, intramuscular in the right thigh. C. Giving the client's caregiver the vaccination information sheet (VIS) when she is leaving so that the family has instructions on adverse effects D. Administering a combination of hepatitis B and Hib in the right thigh while another nurse administers the DTaP vaccination in the left thigh E. Reporting a child with a serious reaction to the correct agency • Answer

D & E

A mother overhears two nurses discussing a measles outbreak. The nurses are talking about the incubation period. The mother asks the nurses why it is important to know the incubation period for a childhood disease. The nurses' reply would be based on the knowledge that the incubation period: Describes a period when the child might be contagious. Determines the severity of the infection. Varies depending on the age of the child. Is a period of time when medications can prevent the development of symptoms.

Describes a period when the child might be contagious.

The nurse is caring for a child diagnosed with thalassemia major who is receiving her first chelation therapy. The parents ask the purpose of chelation therapy. The best response by the nurse is that chelation therapy is done to: Decrease the risk of hypoxia. Decrease the risk of bleeding. Eliminate excess iron. Prevent further sickling of RBCs.

Eliminate excess iron.

Nursing considerations for hemorrhagic cystitis, which may occur with the use of cyclophosphamide (Cytoxan), include: The use of antibiotics. Emptying the bladder frequently. Restricting fluids. Planning for anaphylaxis.

Emptying the bladder frequently.

A child is being treated for HIV infection. In planning health care for this child, the nurse would not include plans to: Keep immunizations current. Instruct family members on how to prevent spread of the organism. Provide information to the child and family about the child's prophylactic drugs. Encourage the family to provide home-schooling.

Encourage the family to provide home-schooling.

A child is admitted to the hospital with an allergic reaction. The physician orders a CBC with differential. The nurse would expect to see an elevation in the level of: RBCs. Hemoglobin. Leukocytes. Eosinophils.

Eosinophils.

A newborn is diagnosed with truncus arteriosus and the nurse is administering prostaglandin E1 (PGE1). What side effect should the nurse monitor the client for? Hypertension Peripheral edema Diaphoresis Fever

Fever

You are completing discharge teaching for the parents of a child newly diagnosed with hemophilia B. Which of the following measures should be included when discussing the control of minor bleeding episodes? Bed rest, oral coagulants, and cold compresses. Gentian violet, ice packs, and constant pressure to the affected areas for 1 hour. Immobilize and elevate the affected area, apply constant pressure to the areas for at least 15 minutes. Elevate of the affected area, alternating warm and cold compresses every 20 minutes.

Immobilize and elevate the affected area, apply constant pressure to the areas for at least 15 minutes.

A mother refuses to have her child receive any immunizations, based on her religious beliefs. The priority nursing diagnosis when planning health teaching for this family is: Knowledge, Deficient on the part of the parent related to potential side effects of vaccines. Injury, Risk for related to vaccine reaction. Pain, Acute related to injection and associated anxiety. Infection, Risk for related to incomplete immunization series.

Infection, Risk for related to incomplete immunization series.

What is the function of the drug class nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)? Interferes with entry of HIV-1 into host cells by inhibiting fusion of the virus with the host cell membranes Disrupts the conversion of RNA to DNA by binding to the viral reverse transcriptase Blocks the function of protease, which is needed for viral formation and growth Inhibits the action of the enzyme viral reverse transcriptase, which is needed to convert RNA to DNA

Inhibits the action of the enzyme viral reverse transcriptase, which is needed to convert RNA to DNA

When telling parents how to apply topical steroids to treat eczema the nurse should explain that: It is applied in a thin layer over affected areas only. It is applied liberally to affected area and adjacent skin. It should only be applied only at night. It is applied to damp skin only.

It is applied in a thin layer over affected areas only.

A child with patent ductus arteriosus is being discharged to home with instructions to take digoxin for congestive heart failure. Which information should the nurse include during discharge teaching to ensure medication safety at home? Select all that apply. Maintain medications in original containers. Keep prescribed antibiotics on hand for unexpected dental procedures. Administer herbal remedies as needed. Monitor apical heart rate prior to administering digoxin. Lock up all medications.

Maintain medications in original containers. Keep prescribed antibiotics on hand for unexpected dental procedures. Monitor apical heart rate prior to administering digoxin. Lock up all medications.

The nurse is providing a teaching session for parents about over-the-counter treatment for head lice. Which of the following will be mentioned as appropriate for treating this problem? Neosporin. Mafenide (Sulfamylon). Silver sulfadiazine (Silvadene). Permethrin (Nix).

Permethrin (Nix).

The mother asks the purpose of aspirin therapy in a child with rheumatic fever. The nurse explains that the purpose is to: Provide comfort and reduce temperature. Prevent cardiac complications. Hasten recovery. Prevent the development of chorea.

Provide comfort and reduce temperature.

A 16-month-old toddler is admitted to the hospital for severe anemia secondary to insufficient iron intake. The child's hemoglobin is 8, hematocrit 23. A blood transfusion is ordered. During the transfusion, the priority assessment would be: Temperature. Respirations. Pulse rate. Observation for rash.

Pulse rate.

15. The nurse is providing health promotion education to the parents of an 18-month-old child with a history of atrial septal defect. Which information should be included in this parent education? Receiving an influenza vaccine annually is important. Avoid live virus vaccines if scheduled for surgery 4 to 6 months from vaccine date. Oral care should be provided when remembered. Begin routine dental visits at 4 years of age.

Receiving an influenza vaccine annually is important.

An adolescent on consolidation chemotherapy for acute lymphocytic leukemia (ALL) asks the nurse to come quickly to evaluate "blood in my urine." The nurse would do which of the following as the most important action? Explain this is normal for these drugs. Measure intake and output. Force fluids to improve the hematuria. Recognize that this is untoward and report the event.

Recognize that this is untoward and report the event.

An infant who has a congenital heart defect comes into the clinic with parental complaints of irritability, pallor, and increased cyanosis that began quickly over the last 30 minutes. As the nurse assesses the infant, the parent asks why the child's color is bluish. The best response by the nurse is, "Skin color is: Related to the time of day." Related to brain function." Related to hemoglobin level and oxygen saturation." Unrelated to your child's condition."

Related to hemoglobin level and oxygen saturation.

A nurse is administering a chemotherapy drug to a patient via central line when the intravenous bag slips and breaks open, spilling the chemotherapy agent on the tile floor. The nurse should: Remove all people from the room until the spill has been cleaned up. Clean up the spill quickly to avoid inhaling fumes from the chemotherapy agent. Use only material that can be washed to clean up the spill. Call housekeeping immediately then proceed with routine nursing care.

Remove all people from the room until the spill has been cleaned up.

A 4-year-old was just diagnosed with impetigo. What is the most important action the nurse should take to make sure it does not spread? Apply bacitracin. Keep it covered. Isolate the child at home. Teach the practice of good hand washing

Teach the practice of good hand washing.

The nurse is developing a discharge teaching plan for the family of a child with Kawasaki's disease. Which of the following is the first priority? Teaching parents to administer aspirin and watch for side effects. Recommending the child avoid contact sports. Monitoring the child's temperature and notifying the doctor if it is over 98.6 degrees F. Establishing home schooling for 6 months.

Teaching parents to administer aspirin and watch for side effects.

Which statements are part of client education for families of children with primary immune deficiency disorders? Select all that apply. Avoid using a dishwasher for the child's bottles. The child should not have live virus vaccines. Fruits and vegetables should be washed and peeled. Cleanse child with mild soap and water during diaper changes. Do not permit the child to have or be exposed to pets.

The child should not have live virus vaccines. Fruits and vegetables should be washed and peeled. Cleanse child with mild soap and water during diaper changes.

The nursing diagnosis for a child undergoing chemotherapy for leukemia is altered nutrition-less than body requirements related to nausea and anorexia. An appropriate goal for this client would be: Administer antiemetics PRN. The child's caloric intake will be within normal range. The child does not complain of nausea. Intake and output are approximately equal.

The child's caloric intake will be within normal range.

A mother calls a clinic nurse to state that a letter had come home with her child from school stating she should examine her child for the nits from Pediculosis capitis. She asks where she should look for these nits. The nurse would tell the mother to examine: The forehead and scalp. In the webs of the fingers. The hair shafts at the nape of the neck. In elbow folds.

The hair shafts at the nape of the neck.

In assessing children with congenital heart defects, the nurse would expect to see clubbing of the fingers and toes in the child diagnosed with: Transposition of the great vessels. Atrial septal defect. Coarctation of the aorta. Patent ductus arteriosus.

Transposition of the great vessels.

What would be an appropriate nursing goal for a 10-year-old girl with eczema of the elbows, hands, and face? Pain will be managed. Spread of infection will be prevented. Well hydrated skin will be maintained. Dietary restriction will be maintained.

Well hydrated skin will be maintained.

After completing discharge teaching for a client with HIV and his mother, which statements indicate they understand their instructions? Select all that apply. "The rash on my face will get worse in the sunlight." "My 9-year-old child is too young to be told about safe sex." "When I feel sick to my stomach, I can wait until the next dose to take my medications." "If my child vomits, I will clean it up with a bleach solution, wearing gloves." "I can show my child affection by hugging or giving a kiss on the cheek."

"If my child vomits, I will clean it up with a bleach solution, wearing gloves." "I can show my child affection by hugging or giving a kiss on the cheek."

A client is to begin radiation therapy after the removal of Wilms' tumor. The parent statement that indicates a lack of understanding of related skin care would be: "We will use loose-fitting clothes on our child." "We will protect our child from sun exposure." "We will keep the area moist with Vaseline." "We will prevent our child from scratching the site."

"We will keep the area moist with Vaseline."

The elementary school nurse is called to the gym when a child with a history of thalassemia complains of dizziness during physical education class. The priority action should be to: Assist the child to the nurse's office to lie down until the dizziness passes. Assist the child to sit in the gym until the dizziness passes. Utilize an ammonia ampoule to prevent loss of consciousness. Assess the child's blood pressure and pulse.

Assist the child to sit in the gym until the dizziness passes.

Which assessment data will be most indicative of a potential complication of Kawasaki's disease? Dermatitis of extremities. Strawberry tongue, erythema of mouth. Change in blood pressure, pulse, skin color. Fever over 5 days, bilateral conjunctivitis.

Change in blood pressure, pulse, skin color.

A child is to receive chemotherapy intravenously with a vesicant drug. The nurse can ensure safe administration of this drug by: Administering the drug using a positive pressure infusion pump. Checking for blood return before, during and after administration of the drug. Maintaining the infusion site below the level of the heart. Delivering the infusion as rapidly as possible.

Checking for blood return before, during and after administration of the drug.

The 10-year-old client in the emergency department has CBC results that include a hemoglobin of eight g/dL and hematocrit of 24 percent. The nursing activity with the highest priority is: Assess and promoting skin integrity. Promoting hydration. Promoting nutrition. Conserving energy.

Conserving energy.

An 11-month-old child with iron-deficiency anemia is hospitalized for a respiratory infection. Her mother voices confusion as to the connection between her daughter's anemia and her infection. The nurse would explain that children with iron-deficiency anemia are: Equally susceptible to infection as other children. More susceptible to infection than other children. Less susceptible to infection that other children. At risk for respiratory infections because the inability to produce leukocytes.

More susceptible to infection than other children.

A child is receiving chemotherapy to induce remission in acute leukemia. When considering common side effects of chemotherapy, an appropriate nursing diagnosis early in the course of therapy would include: Sleep Pattern, Disturbed. Mucous Membrane: Oral, Impaired. Infection, Risk for. Tissue Perfusion: Peripheral, Risk for Ineffective.

Mucous Membrane: Oral, Impaired.

A 4-year-old child is having scratch tests for allergies. In teaching the family about the planned tests, the nurse should include the information that: This test allows us to rule out one or two specific antigens. The scratch test is the most sensitive allergy test. Results can be obtained in 30 minutes. The scratch test involves drawing a small amount of blood from the client.

Results can be obtained in 30 minutes.

During a routine visit to the hematology clinic, the parents of a 10-year-old with hemophilia voice their concerns as to their son's physical activity in relation to the potential for injury and bleeding. Physical activities the nurse can suggest include: Basketball. Baseball. Swimming. Gymnastics.

Swimming.

The nurse is caring for several children in a hospital unit where there has been a recent outbreak of diarrhea. None of these children were admitted for diarrhea, but the nurse is aware that they may be exposed. Of the children on the unit, the one most susceptible would be the: Toddler with SCID. Preschooler in traction for a fractured femur. School-age child with eczema. Teenager with frequent stools secondary to malabsorption syndrome.

Toddler with SCID.

A parent of a child with a third-degree burn asks why the nurse keeps spreading white cream on the child's burns. The nurse explains that the cream is mafenide (Sulfamylon), which is being applied to the burned area because it is a: Lubricant that will keep the area well hydrated. Topical antibiotic that inhibits infection. Tissue hormone that stimulates new tissue growth. Steroid that reduces edema at the site.

Topical antibiotic that inhibits infection.

Which of the following would be appropriate home care instructions for a family that has a lice infestation? Immerse combs and brushes in boiling water for 30 minutes to kill lice. Vacuum floor and furniture to remove hair that might have live nits. Take the child's clothing and bed linens to a dry cleaner for sanitation. Use commercial anti-lice sprays on furniture and mattresses.

Vacuum floor and furniture to remove hair that might have live nits.

An infant, aged 2 months, has oral thrush. Which medication will the nurse teach the parents to administer to treat this infection? A. Bacitracin B. Zinc oxide C. Hydrocortisone D. Nystatin • Answer

The nurse's assignment for the shift includes caring for a child with infective endocarditis. To provide quality care, the nurse is reviewing the etiology of this disease process. Which statement is most accurate? A. Infective endocarditis develops in response to weakened cardiac muscle. B. Infective endocarditis is the result of an autoimmune response. C. Infective endocarditis is a genetic malformation. D. Infective endocarditis is caused by a bacteria or fungus. • Answer

The parents of a child who has sustained a serious burn ask about complications. What is the most common complication seen in children during the recovery and management phase of burn treatment? A. Metabolic acidosis B. Shock C. Asphyxia D. Wound infection • Answer

What clinical manifestations would a nurse expect to find when examining a male client with suspected acute lymphoblastic leukemia (ALL)? a. Bony mass at the knee b. Shortened limbs c. An extra digit on the foot d. Swollen testicle i. Answer

Parents have brought their child to the emergency department (ED) after the child fell against a metal fire pit during a backyard barbecue. At first glance, the nurse estimates that the burned area spans about five widths of the child's palm. What percentage of the child's body is documented as burned? A. 10% B. 20% C. 15% D. 5% • Answer

The nurse initiates the diagnosis of alteration in nutritional status when caring for an infant with heart failure. What nursing intervention will assist in meeting the needs of the client with this diagnosis? A. Hold infant at a 15degrees° angle during feeding B. Encourage bottle feedings to last 45 min. C. Weigh infant once each week. D. Provide small frequent feedings. • Answer

The nurse is assessing an infant with a skin rash. Which finding is suggestive of atopic dermatitis? A. Pruritus and red patches with waxy scaling B. Narrow, raised, irregular channels on the epidermis with some bleeding and scarring C. Waxy scaling of the scalp and rash on the face, scalp, and skin folds of the neck and axillae D. Pruritus, red patches, vesicles, exudate, and crusting • Answer

The nurse is caring for a 6-year-old client with thalassemia. The client is diagnosed with splenomegaly. Which medical treatment should the nurse anticipate for the client? A. A bone marrow transplant B. Monthly transfusions of packed red blood cells C. Treatment of hemosiderosis with deferoxamine D. Removal of the spleen by surgical procedure • Answer

The nurse is discharging a pediatric client from the emergency department (ED) following treatment for a second-degree burn. When should the nurse tell the parents to receive follow-up care for the client? A. Within 72 hr of initial treatment B. Within 96 hr of initial treatment C. Within 24 hr of initial treatment D. Within 48 hr of initial treatment • Answer

The nurse is educating a women's community group about congenital heart disorders. What factor should the nurse identify as placing a child at a greater risk for being born with a congenital heart disorder? A. Fetal exposure to a bacterial infection B. Mother infected with gonorrhea C. Young age of mother D. Chromosomal abnormality such as Down syndrome • Answer

The nurse reviews the orders for fluid replacement for a newly admitted burned child. The child's parent asks why intravenous (IV) fluids are necessary. Which response is most appropriate by the nurse? A. "IV fluids are necessary to enhance wound healing." B. "IV fluids are not necessary for your child. I will speak to the health care provider." C. "IV fluids are necessary to prevent dehydration." D. "IV fluids are necessary to maintain the cardiovascular and renal systems." • Answer

Which of the following is the most important message to impart to parents of a child with disseminated intravascular coagulation (DIC)? A. The medical staff will make all urgent decisions about the child's care. B. Their cultural practices must never interfere with the child's care. C. Support is available to them from the National Hemophilia Foundation. D. The child must never be left alone in the hospital room. • Answer

A clinic nurse is providing education to the mother of a child who is being treated medically for a ventricular septal defect. The nurse informs the mother that the child will require antibiotic prophylaxis to prevent bacterial endocarditis in what situation? Prior to a dental procedure When recovering from chickenpox After a playground accident Before receiving immunizations

Prior to a dental procedure

Immediately following the birth of an infant, the nurse is completing a physical assessment. What manifestation indicates the infant may have a heart defect associated with decreased pulmonary bloodflow? Poor feeding Clubbing of fingers and toes Profound cyanosis that does not respond to oxygen Fatigue

Profound cyanosis that does not respond to oxygen

The parents of a client with sickle cell anemia are asking for information about future pregnancies. Neither parent has sickle cell anemia. The nurse would provide them with the information that any future pregnancies will have a: 1 in 4 chance of producing a child with sickle cell trait. 1 in 4 chance of producing a child with sickle cell anemia. 1 in 2 chance of producing a child with neither sickle cell disease or trait. 1 in 2 chance of producing a child with sickle cell anemia.

1 in 4 chance of producing a child with sickle cell anemia.

A 10-year-old child has just received his first immunization of influenza vaccine. His lips begin to swell, and he states, "It feels like my throat is closing shut and my chest is tight when I breathe." The nurse recognizes these signs as: A local allergic reaction to the influenza vaccine injection. An anxiety reaction due to receiving an injection. A common systemic allergic reaction to immunization. A life-threatening reaction to the influenza vaccine.

A life-threatening reaction to the influenza vaccine.

During rounds, the interdisciplinary team is discussing a child with leukemia who has just been diagnosed as terminal. The nurses describe the mother's behavior as angry, claiming the nurses are not providing care for her child. The team leader will focus on the probable cause of the mother's anger, which is: Poor care on the part of the nurses. Lack of attention for the mother's needs. Overwhelming guilt for having caused the leukemia. A stage of bereavement over the anticipated loss of the child.

A stage of bereavement over the anticipated loss of the child.

A 3-year-old girl undergoing radiation therapy for a neoplasm states she is afraid of the large machines in the radiation department. To calm the child during the procedure, the nurse could: Allow the child to keep a favorite stuffed animal with her during the therapy. Stay with her during the therapy. Allow a parent to stay with her during therapy. Encourage her to think about a favorite place during the therapy.

Allow the child to keep a favorite stuffed animal with her during the therapy.

The mother of a 1-year-old child says that breast-feeding her infant is sufficient to provide immunity. She does not want to sign the permit for immunizations. What is the nurse's best response? Discuss active and passive immunity. Tell her immunizations are legally mandatory. Ask about the mother's diet. Allow her the right to refuse.

Discuss active and passive immunity.

The elementary school nurse is assessing and giving initial care to a hemophiliac who has a significant pain in his knee. The nurse suspects hemarthrosis. As the nurse waits for his family to pick the child up, the nurse would: Maintain joint mobility with passive range of motion exercises. Elevate the leg above his heart. Administer children's aspirin or ibuprofen for pain. Apply warm soaks to reduce the swelling.

Elevate the leg above his heart.

The laboratory finding that would be seen in the cyanotic heart disease client but not in the acyanotic heart disease client would be a(an): Elevated pO2. Elevated hemoglobin. Decreased hematocrit. Decreased pCO2.

Elevated hemoglobin.

You are assigned to the postoperative care of a client with a below-the-knee amputation for osteogenic sarcoma. Nursing care of the child would include: Maintaining bedrest until able to use permanent prosthesis. Keeping stump elevated continuously until prosthesis applied. Applying a dressing to the stump that allows continuous visualization of the distal stump. Encouraging early visits from friends.

Encouraging early visits from friends.

A client is admitted with a diagnosis of "rule out rheumatic fever." Based on Jones criteria, the nurse assesses for: Polyarthritis and dental caries. Fever, headache, and low red blood cell count. Chorea, muscle weakness, and decreased erythrocyte sedimentation rate. Erythema, polyarthritis, and elevated antistreptolysin-O (ASO) titer.

Erythema, polyarthritis, and elevated antistreptolysin-O (ASO) titer.

The nurse is working with the family of a toddler who is being treated for iron-deficiency anemia. In teaching dietary considerations, the nurse will instruct the family to add sources of iron and: Vitamin D and thiamine. Calcium and riboflavin. Carbohydrates and vitamins. Folic acid and proteins.

Folic acid and proteins.

Appropriate interventions for a 2-year-old with nausea and vomiting related to chemotherapy would include: Giving antiemetics at the start of treatment and on a fixed schedule rather than on demand. Offering fluids in large amounts to combat dehydration. Using foods with strong odors to stimulate appetite. Assessing ability to drink independently.

Giving antiemetics at the start of treatment and on a fixed schedule rather than on demand.

A teenage girl receiving chemotherapy has a nursing diagnosis of Body Image, Disturbed. Nursing interventions to promote a positive body image would include: Placing pictures of the girl before chemotherapy around the room to remind her of what she really looks like. Pointing out teenage girls who have less hair than she does. Holding a beauty day with a cosmetician to teach her how to put on makeup. Having a chaplain talk to the girl about inner beauty.

Holding a beauty day with a cosmetician to teach her how to put on makeup.

A child with neoplastic disease is in terminal condition. The child is receiving a large dose of morphine by continuous infusion for pain control. After the mother and nurse both reported to the physician that the child continues to be in severe pain, the physician has ordered a small increase in the morphine dosage. The nurse should: Refuse to administer the drug because the child may develop tolerance to the dose. Stop the infusion until another physician can check the order. Increase the dose as prescribed. Maintain the drug at the previous level and report the doctor for drug misuse.

Increase the dose as prescribed.

The nurse is developing a discharge plan for a family with a toddler who has undergone a successful repair of a ventricular septal defect (VSD). The parents question why the child is being sent home on antibiotics when no infection is present. The nurse would explain to the parents this is prophylactic to prevent the complication of: Infective endocarditis. Pulmonary embolism. Cerebrovascular accident. Gastritis.

Infective endocarditis.

In planning care for a 4-year-old with anemia secondary to chemotherapy and radiation therapy, the nurse would include: Frequent play periods. A diet focused on food preferences. Interviewing parents about the child's functional health patterns. Allowing the child to plan daily activities.

Interviewing parents about the child's functional health patterns.

When assessing a teenager with eczema, the nurse would expect to find what kind of skin lesions? A reddened macular, papular rash. Large lichenified plaques. Vesicles and pustules. Bullae and papules.

Large lichenified plaques.

A toddler with Kawasaki's disease is ordered to receive aspirin therapy. Typical administration of aspirin for Kawasaki's disease would include which of the following principles? High doses of aspirin should be given while fever is high. Length of aspirin therapy is related to child's response. Aspirin dose increases after fever is gone. Aspirin dosage is unrelated to platelet count.

Length of aspirin therapy is related to child's response.

A mother brings her child to clinic complaining of malaise and low-grade temperature. In reviewing the child's medical history, the nurse notes the child is behind on immunizations. When the nurse assesses the mouth of this child, koplik spots, reddish spots, are seen on the buccal mucosa. The nurse suspects: Mumps. Measles (Rubeola). Chickenpox. Rubella.

Measles (Rubeola).

A newborn with possible hypoplastic left heart disease is to be admitted to the nursing unit. Which drug should be available for use? Digitoxin (Crystodigin). Prostaglandin E1 (Prostin VR). Morphine. Testosterone (Andro).

Prostaglandin E1 (Prostin VR).

The nurse is caring for a child who is being treated for extensive bleeding in the emergency department. The source and extent of bleeding are being determined as the nurse is trying to control the bleeding. Which of the following actions takes priority? Obtain the client's history. Talk with the family regarding the risk of HIV and hepatitis C with blood transfusions. Replace blood volume. Provide psychosocial support to the family.

Replace blood volume.

The nurse is working with the family of an 8-month-old infant with severe nutritional anemia. In providing dietary recommendations, the nurse should instruct the family to: Switch the baby to cow's milk. Delay the introduction of table food in the diet. Restrict the amount of milk or formula in the baby's diet to 1 quart per day. Provide dietary iron sources such as peanuts and unsweetened chocolates.

Restrict the amount of milk or formula in the baby's diet to 1 quart per day.

A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. What is the priority care for this child? Assess growth and development. Begin dental care. Update vaccinations. Complete hearing screening.

Update vaccinations.

To decrease skin irritation in children with eczema, the parents should be instructed to do which of the following: Take hot baths (not showers) daily. Liberally apply a lotion of choice over entire body. Use fabric softener for all clothes. Use mild soap only as needed

Use mild soap only as needed.

A 3-month-old child was diagnosed with transposition of the great vessels. The mother cannot stop sobbing and tells the nurse she feels guilty about her child's condition. The nurse's best response is to: Agree that a teratogenic stressor could cause this. Disagree with her feeling quilt. Use therapeutic listening and support. Talk about the wonderful technology available for cures.

Use therapeutic listening and support.

A nurse is caring for an adolescent who had acne and is prescribed isotretinoin 13-cis-retinoic acid (Amnesteem). Which of the following laboratory findings should be monitored? A. Cholesterol and triglycerides B. BUN and creatinine C. Serum potassium D. Serum sodium • Answer

An adolescent client with a history of heart failure is admitted with complaints of a persistent dry cough. When reviewing the client's medication profile, what medication should the nurse question about a potential side effect? A. Lisinopril B. Furosemide C. Carvedilol D. Propranolol • Answer

An adolescent is brought to the clinic after spending several hours walking barefoot on a white-sand beach on a hot day. The teen is having trouble walking and complains of pain. The nurse notes blistering and erythema on the feet. What does she recognize the condition as? A. Partial thickness, second-degree burn B. Superficial, partial thickness burn C. Full thickness, third-degree burn D. First-degree burn • Answer

The nurse is caring for a 10-year-old client with thalassemia who has had a splenectomy. Which nursing diagnosis would be appropriate for this client? A. Risk for sepsis B. Inadequate oxygenation C. Activity intolerance D. Risk for cellular hypoxia • Answer

The nurse is caring for a child who is recovering from a serious chemical burn. Which nursing diagnosis takes priority for this child? A. Impaired skin integrity B. Deficient knowledge treatment of burns C. Anxiety D. Risk for infection • Answer

The nurse is planning care for a 3-month-old infant with eczema. Which intervention will take the highest priority? A. Preventing infection of lesions. B. Keeping the baby content. C. Applying antibiotics to lesions. D. Maintaining adequate hydration. • Answer

When presented with an acute lymphoblastic leukemia (ALL) treatment plan for his child, the father asks why the treatment regimen contains so many drugs. After an explanation is provided by the nurse, which statement by the father indicates an understanding of the rationale for the multiple drug treatment plan? a. "A multiple drug regimen is used to treat cells that may be resistant to some of the chemotherapeutic agents used as treatment." b. "Chemotherapeutic drugs lose effectiveness over time." c. "ALL is very difficult to treat in children." d. "My child is receiving multiple drugs to treat ALL because the health care provider is unsure which drug will have the best effect on the disease." i. Answer

A child with acute lymphoblastic leukemia (ALL) is sent home with hospice services. Which statement by the child's parents indicates they understand the primary goal of hospice care? a. "The goal of hospice is to provide the child with adequate symptom management to promote comfort at the end of life." b. "The goal of hospice is to assist the child meet developmental tasks prior to death." c. "The goal of hospice is to promote family unity in decision making at the end of life." d. "The goal of hospice is to prevent costly hospitalization at the end of life." i. Answer

A child with cellulitis of the leg is being treated at home. Following client teaching, which statement by the mother indicates a need for additional education? "I will give my child antibiotics as ordered until he has completed the entire bottle of medication." "It's OK if he wants to have friends over to play board games." "From now on, I will seek medical treatment whenever my child gets a cold or the flu." "If the leg swells further, I should call my doctor."

"From now on, I will seek medical treatment whenever my child gets a cold or the flu."

A clinic nurse is providing education to the mother of a child who is being treated medically for a ventricular septal defect. The nurse informs the mother that the child will require antibiotic prophylaxis to prevent bacterial endocarditis in what situation? A. Prior to a dental procedure B. When recovering from chickenpox C. Before receiving immunizations D. After a playground accident • Answer

A nurse is applying a 5% permethrin lotion to a toddler with scabies. What is the best way to apply this lotion? A. Apply the lotion over the entire body from the neck down, as well as on the scalp and forehead. B. Apply the lotion only to the hands. C. Apply the lotion only on the areas with evidence of scabies activity. D. Apply the lotion to the scalp only. • Answer

A child has sustained a minor burn. The child's parents ask if there are any special dietary needs to enhance healing. What should be included in increased amounts in the child's diet to enhance healing? A. Protein B. Minerals C. Fats D. Carbohydrates • Answer

A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following is an appropriate nursing intervention to manage this client's pain? A. Administer morphine sulfate via IV continuous infusion B. Administer meperidine (Demerol) IM as needed C. Administer acetaminophen (Tylenol) PO ever 4 hours D. Administer hydrocodone (Vicodin) PO every 6 hours • Answer

After completing discharge teaching for a client with HIV and his mother, which statements indicate they understand their instructions? (Select all that apply) A. "I can show my child affection by hugging or giving a kiss on the cheek." B. "My 9-year-old child is too young to be told about safe sex." C. "When I feel sick to my stomach, I can wait until the next dose to take my medications." D. "The rash on my face will get worse in the sunlight." E. "If my child vomits, I will clean it up with a bleach solution, wearing gloves." • Answer

A & E

Which clients would be at risk for acquiring HIV? Select all that apply. A health care worker who received an accidental needle stick A child born to an HIV-positive mother A client who kissed an HIV-positive relative A 6-month-old breastfeeding infant whose mother is HIV positive A 2-year-old with a bruise from a bite by an HIV-positive child

A health care worker who received an accidental needle stick A child born to an HIV-positive mother A 6-month-old breastfeeding infant whose mother is HIV positive

For which clients is the administration of scheduled vaccinations contraindicated? (Select all that apply) A. A 15-year-old female who has been having unprotected sex who needs the human papillomavirus (HPV) vaccine. B. A 2-year-old client with a history of eczema, asthma, and an allergy to eggs and dairy. C. A 6-year-old client whose mother states she does not want her child to receive the vaccine. D. A 4-year-old client who received IV immunoglobulin (IVIG) for Kawasaki's disease when he was 2 years old. E. A 6-month-old with a runny nose whose temperature is 98.8degrees F (37.1degrees C). • Answer

A, B, & C

The nurse is giving discharge instructions for a child with minor valve damage from rheumatic fever. What should the nurse include in the teaching? (Select all that apply) A. The child may require surgery in the future. B. The child will be at risk of developing an embolus as an adult. C. The child will require secondary prophylaxis. D. The child will be at risk of developing ventricular fibrillation later in life. E. The child can resume normal activities after discharge. • Answer

A, B, & C

Which clients would be at risk for acquiring HIV? (Select all that apply) A. A health care worker who received an accidental needle stick B. A 6-month-old breastfeeding infant whose mother is HIV positive C. A child born to an HIV-positive mother D. A 2-year-old with a bruise from a bite by an HIV-positive child E. A client who kissed an HIV-positive relative • Answer

A, B, & C

Which factors put a 5-month-old infant at risk for acquiring communicable diseases? Select all that apply. A. Oral exploration of objects in the environment B. Fewer previous infections C. Inability to use antibacterial soaps because of sensitive skin D. Immature immune system E. Inability to digest fruits and vegetables • Answer

A, B, & D

The nurse is caring for a 9-year-old client with iron deficiency anemia. When providing discharge teaching about iron supplements, what information should the nurse give to the caregivers? Select all that apply A. Iron supplements can cause nausea on an empty stomach. B. Give with orange juice to increase absorption. C. Give with dairy products to increase absorption. D. Iron is a safe supplement and cannot be toxic. E. Iron supplements can cause constipation. • Answer

A, B, & E

The nurse, who is explaining hydrotherapy to an adolescent burn victim, states that hydrotherapy is used for what reason? (Select all that apply) A. Cleansing extensive wounds before debridement B. Increasing vasodilation and circulation C. Protecting against fluid loss D. Decreasing the need for an allograft E. Speeding healing • Answer

A, B, & E

The nurse is preparing discharge teaching for a school-aged child with heart failure. Which information about play and proper environment should the nurse review with the parents and child? Select all that apply. A. Educate child to self-monitor and limit exercise when necessary. B. Prevent child from playing outside on hot weather days. C. Dress in clothing that wicks away moisture. D. Restrict fluids while the child is playing. E. Allow child to participate in team sports. • Answer

A, B, C

Which statements by the nurse about the pathophysiology and risk factors for disseminated intravascular coagulation (DIC) are accurate? (Select all that apply) A. "Sepsis is a risk factor for DIC." B. "The clotting pathways are activated systemically, causing excessive thrombin production." C. "DIC can cause multisystem organ dysfunction." D. "DIC is an acquired condition, not hereditary." E. "The delayed prothrombin time (PT) and partial thromboplastin time (PTT) cause excessive bleeding." • Answer

A, B, C, & D

A nurse educator is teaching a group of nursing students about burns. The nurse knows the students have understood the lesson when the students are able to state that the severity of a burn is determined by which characteristic? (Select all that apply) A. The percentage of body surface area (BSA) affected B. The depth of the burn injury C. The condition of the wound edges D. The age of the child E. The specific body part involved • Answer

A, B, D, & E

The nurse is preparing to discharge a pediatric client following an extensive burn. The nurse knows that it is essential to include what in the discharge instructions to the client and family? (Select all that apply) A. Nutrition and dietary needs B. Use of a sling to decrease use of extremities C. Signs of infection and actions to take D. Protection of the burned surface E. Range of motion exercises • Answer

A, C, D, & E

A nurse is caring for a child who is receiving chemotherapy. Which of the following are appropriate actions for the nurse to take? SATA a. Monitor for signs of bleeding b. Administer routine immunizations c. Obtain rectal temperatures d. Avoid peripheral venipunctures e. Limit visitors i. Answer

A, D

Which treatment options are appropriate for beta-thalassemia? (Select all that apply) A. Splenectomy B. Intravenous opioids such as hydromorphone and morphine C. Hematopoietic stem cell transplant D. Monthly transfusion of packed red blood cells E. Bone marrow transplant • Answer

A, D & E

The nurse is planning care for an 18-month-old child diagnosed with tetralogy of Fallot. Which interventions should the nurse implement to assist in managing hypercyanosis? (Select all that apply) A. Apply oxygen. B. Avoid administering dopamine. C. Place child in supine position. D. Use opioids to manage pain. E. Administer packed red blood cells. • Answer

A, D, & E

A nurse is caring for a toddler who has a Wilm's tumor. Which of the following should be included in the plan of care? a. Abdominal palpation to identify size of tumor b. Preparation for surgery c. Teaching about dialysis d. Obtaining 24-hr urine specimen i. Answer

During a routine clinic visit, a mother tells the nurse that she is concerned because her infant has a diaper rash that will not clear up. The nurse notes a very red area with raised, scaly plaques deep in the skin folds of the diaper area. After consultation with the health care provider, what does the nurse tell the mother? A. "This is seborrheic dermatitis, which will clear up with daily cleaning of the diaper area with soap and water." B. "This is diaper dermatitis, which can be treated with a topical antifungal medication." C. "This is impetigo. You will need to wear gloves when changing the diaper because it is very contagious." D. "The rash is cellulitis, and you will need to apply a skin barrier to help prevent it from occurring in the future." • Answer

Following discontinuation of treatment for acute lymphoblastic leukemia (ALL), the nurse provides which recommendation as anticipatory guidance regarding future health care needs following treatment for ALL? a. "Only clients diagnosed with high-risk ALL require follow-up after treatment." b. "Follow-up is necessary for several decades due to the risk of secondary cancers and long-term complications following treatment for cancer." c. "No follow-up health care is needed once treatment is complete." d. "Follow-up is necessary only if a problem is suspected." i. Answer

The diagnosis of rheumatic fever is being ruled out for a child. The nurse is obtaining a history from the child's parents. Which would be the most significant finding for this diagnosis? A. The child had a rash a week ago that went away. B. The child was treated for strep throat 3 weeks ago. C. The child has had a decreased attention span. D. The child has had an intermittent fever for 4 days. • Answer

What is the function of the drug class nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)? A. Disrupts the conversion of RNA to DNA by binding to the viral reverse transcriptase B. Inhibits the action of the enzyme viral reverse transcriptase, which is needed to convert RNA to DNA C. Interferes with entry of HIV-1 into host cells by inhibiting fusion of the virus with the host cell membranes D. Blocks the function of protease, which is needed for viral formation and growth • Answer

A nurse is providing teaching to the mother of an infant who is to start taking digoxin (Lanoxin). Which of the following instructions should the nurse include? A. Do not offer your baby fluid after giving the medication B. Digoxin increases your baby's heart rate C. Give the correct dose of medication at regularly scheduled times D. If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount • Answer

The nurse is providing discharge teaching about medication administration to the parents of a child diagnosed with heart failure. What statement by the parents indicates understanding of the teaching? A. "We can administer over-the-counter medication as needed." B. "We will administer the medication using a teaspoon." C. "We must administer the medication at the same time every day." D. "We should call the medication candy if child refuses to take it." • Answer

When treating a 6-year-old child with oral thrush (candidiasis), what education is important to provide to the parents? A. Have the child swish the medication around in the mouth and then spit it out. B. Give the medication with milk or formula to increase absorption. C. Apply the medication to the child's buccal mucosa and tongue, then have the child swallow. D. Administer the oral antifungal medication, being careful to avoid the teeth. • Answer

A nurse provides discharge instructions to a client and his parents following hospitalization to receive chemotherapy. Which discharge instructions should the nurseprovide? Select all that apply. a. Perform vigorous mouth care at least 2 times a day. b. Perform hand hygiene no more than 2 times a day. c. Examine intravenous (IV) sites daily for signs of infection. d. Avoid large crowds when neutrophil counts drop. e. Take acetaminophen and rest for a fever of 101degrees°F (38.3degrees°C). i. Answer

C, D

A nurse is teaching the parent of a child who has a Wilms' tumor. Which of the following statements should the nurse include in the teaching? (SATA) a. Your child will need to have chemotherapy for 12 months b. Wilms' tumors are typically genetic in nature c. Surgery is done usually w.in 48 hrs of dx d. Palpating tumor could cause spread of cancer e. Further tx will start immediately after surgery i. Answer

C, D, E

A child has received IVIG for the treatment of Kawasaki disease. The nurse informs the child's family that any immunizations with a live virus vaccine should be postponed for how long? A. At least 4 months B. At least 18 months C. At least 11 months D. At least 24 months • Answer

C. •

A client with suspected acute lymphoblastic leukemia (ALL) is admitted with severe petechiae. The nurse anticipates orders for what laboratory tests and treatment? a. Complete Blood Count (CBC) and packed red blood cells b. Liver Function Tests (LFTs) and albumin c. Immunoglobulins (IG) d. Complete Blood Count (CBC) and platelets i. Answer

An adolescent is in the clinic for a follow-up to a consultation 6 weeks ago for acne. The adolescent expresses frustration with the retinoid treatment, saying the acne has gotten worse, not better. The most appropriate response by the nurse is A. "Be patient. It will improve soon." B. "It will take 6 months of treatment to see improvement." C. "We can change the medication and see if that makes a difference." D. "This is a sign the medication is working. It is pushing out the comedones that are plugging the pores." • Answer

A newborn diagnosed with hypoplastic left heart syndrome is scheduled for a heart transplant. The nurse informs the mother that the transplanted heart usually lasts for how long before another transplant is needed? A. 5 to 9 years B. 0 to 4 years C. 16 to 20 years D. 10 to 15 years • Answer

D •

A child is admitted to the hospital with a diagnosis of leukemia. Presenting lab values show low numbers of platelets and red blood cells. A very high white blood cell (WBC) count is also noted. An appropriate nursing diagnosis related to these findings would include: Infection, Risk for. Gas Exchange, Impaired. Nutrition, Imbalanced: Less than Body Requirements. Fluid Volume: Deficient.

Gas Exchange, Impaired.

A child diagnosed with pulmonic stenosis is experiencing clubbing of fingers and toes. When planning care for this child, what diagnosis is priority for the nurse to initiate? Acute pain Risk for injury Risk for embolus Constipation

Risk for embolus

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