Peds ATI 2019 A
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? a. provide small, frequent meals for the child b. schedule time in the play room for the child c. weigh the child weekly d. maintain the child in a supine position
A
A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? a. "Shake the medication prior to administration." b. "Provide the medication through a straw." c. "Rinse the child's mouth with water immediately after giving the medication." d. "Mix the medication with applesauce if the child dislikes the taste."
A
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? a. hematocrit 28% b. hemoglobin 13.5 g/dL c. WBC count 8000mm^3 d. platelets 250000/mm^3
A
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? a. hgb 8.5g/dL b. WBC 9500/mm^3 c. prealbumin 18mg/dL d. platelets 300000/mm^3
A - A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area. a. zinc oxide b. antibiotic ointment c. talcum powder d. antiseptic solution
A - Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take? a. change the child's position every 2hrs b. clean the peripheral pin sites with chlorhexidine solution every 4 days c. assess peripheral pulses once every 4 hours d. ensure that the head of the bed is elevated to a 90 degree angle
C - Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure? a. apply topical antimicrobial ointment to the child's wound. b. place a mesh gauze dressing over the child's wound c. administer an analgesic to the child d. initiate prophylactic antibiotic therapy for the child
C - Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? a. inflamed throat with exudate b. purulent eye drainage c. dry, hacking cough d. kolpik spots on a buccal mucosa
C - The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take? a. obtain a sputum specimen b. perform an Allen test c. perform a finger stick d. obtain a stool specimen
C - The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? a. insert a nasogastric tube b. initiate prophylactic antibiotic use c. cleanse the affected area with mild soap and water d. apply a topical corticosteroid to the affected area
C - To remove any loose tissue that could cause infection.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order of performance) a. remove the tape securing the catheter b. occlude the IV tubing c. Turn off the IV pump d. apply pressure over the catheter insertion site
C, B, A, D
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? a. wheat crackers b. rye bread c. barley soup d. white rice
D - The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.
A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." b. "I should position the car seat harness 1" above my baby's shoulders." c. "I will make sure that the car seat is placed at a 90 degree angle." d. "I will pad my baby's car seat with a blanket for traveling long distances"
A - Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? a. loud, hard murmur b. dysrhythmias c. weak femoral pulses d. high BP
A - The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make? a. "You can sign the consent form because you are married" b. "Your spouse should sign the consent form for you." c. "Your parent should sign the consent form for you" d. "You can appoint a legal guardian to sign the consent form."
A - The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control? a. have a designated stethoscope in the infant's room. b. place the infant in a room equipped with negative airflow c. administer palivizumab as prescribed for the infant d. remove gloves after leaving the infant's room
A - The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? a. place the child in a side-laying position b. delay documentation until the child is fully alert c. give the child a high-carb snack d. administer an oral sedative to the child
A - The nurse should place the child in a side-lying position to prevent aspiration.
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? a. a school age child who has sickle cell anemia and reports decreased vision in the left eye b. a school age child who has cystic fibrosis and a frequent nonproductive cough c. a preschooler who has asthma and a peak flow meter reading in the green zone d. an adolescent who has meningitis and reports a sensitivity to lights and noise
A - When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? a. recurrent urinary tract infections b. symmetric burns of the lower extremities c. failure to thrive d. lack of subcutaneous fat
B
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take? a. instill a 500ml tap water enema b. give morphine 0.05mg/kg IV c. administer polyethylene glycol 1g/kg PO d. apply a heating pad to the child's abdomen
B
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? a. laryngeal edema b. flank pain c. distended neck veins d. muscular weakness
B
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? a. place a cardiac monitor on the adolescent prior to the procedure b. apply topical analgesic cream to the site 1hr prior to the procedure c. keep the adolescent in a semi-fowler's position for 4hrs following the procedure d. restrict fluids for 2hrs following procedure
B
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? a. potassium 2.9 mEq/l b. sodium 140 mEq/L c. urine specific gravity 1.035 d. BUN 25 mg/dL
B
A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? a. "I will puncture the pad of my finger when I am testing my blood glucose." b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." c. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." d. "I will decrease the amount of fluids I drink when I am sick."
B
A nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? a. occupational therapist b. speech therapist c. respiratory therapist d. physical therapist
B - A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? a. negative leukocyte esterase b. serum creatinine 3.0 mg/dL c. negative urine protein d. urine output 40ml/hr
B - Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning.
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? a. purulent nasogastric drainage b. absence of peristalsis c. passage of dark stool with mucus d. WBC count 6000mm^3
B - The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning.
A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? a. BP 90/50 b. RR 45 c weight 14.5 kg (32lbs) d. HR 110
B - The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect? a. hyperactive bowel sounds b. abdominal distention c. bradycardia d. bloody stool
B - The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching? a. "My child will have a cast until healing is complete." b. "My child will receive antibiotics for several weeks." c. "My child can return to playing sports once they have been discharged." d. "My child needs to be in contact isolation."
B - The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? a. reports a headache as 6 on a 0-10 pain scale b. petechiae on the lower extremities c. nuchal rigidity d. positive Kernig's sign
B - The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? a. prednisone b. epinephrine c. diphenhydramine d. albuterol
B - This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply) a. negative Babinski reflex b. ankle clonus c. exaggerated stretch reflexes d. uncontrollable movements of the face e. contractures
B, C, E
A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? a. identifies right from left hand b. uses a utensil to spread butter c. cuts an outlined shape using scissors d. draws a stick figure with seven body parts
C
A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? a. blood pressure 130/90 mm Hg b. HR 60/min c. Temp 39.1 Degrees C (102.4 Degrees F) d. urinary output 100ml/hr
C
A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? a. use surgical asepsis when providing routine care for the child b. administer the measles, mumps, and rubella (MMR) vaccine to the child c. screen the child's visitors for indications of infection d. infuse packed RBCs
C
A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take? a. place the child in a prone position for the immunization b. request that the child's caregiver leave the room during the immunization c. administer the immunization using a 24 gauge needle d. inject the immunization slowly after aspiration for 3 seconds
C
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? a. decreased cerebrospinal fluid pressure b. decreased WBC count c. increased protein concentration d. increased glucose level
C
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? a. expresses a reluctance to leave home b. provides a detailed description of how the burns occurred c. denies discomfort during assessment of injuries d. describes strong relationship with peers
C
A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? a. sodium 148 mEq/L b. urine specific gravity 1.020 c. mental confusion d. weak peripheral pulses
C - A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? a. "it is important that you provide emotional support for your family at this time." b. "You have to do what you feel is best. Everything will turn out fine." c. "I know how you feel. This is an extremely stressful time for your family." d. "Let's talk about some of the ways you have handled previous stressors in your life."
D - This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider? a. excoriated scrotal area b. multiple capillary hemangiomas c. depressed posterior fontanel d. substernal retractions
D - When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? a. skin breakdown b. hypotension c. hyperpyrexia d. tachypnea
D - When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? a. playing pat-a-cake b. using a push-pull toy c. creating a scrapbook d. playing dress-up
D - The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.
A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? a. elevate the head of the child's bed b. insert a large bore IV catheter for a child c. determine the allergen that caused the child's reaction d. administer epinephrine IM to the child
D
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? a. place the child in a room with a positive pressure airflow b. place the child in a room with a negative pressure airflow c. initiate contact precautions for the child d. initiate droplet precautions for the child
D
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? a. apple juice b. peanut butter c. chicken broth d. oral rehydration solution
D
A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury. Which of the following interventions should the nurse include in the plan? a. position the infant side-lying with their head at a )-5 degree angle b. perform a neurological assessment Q4hrs c. suction the infant's nares to remove secretions d. implement seizure precautions for the infant
D
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? a. instruct the parents to decrease the calcium in their toddler's diet b. prepare the toddler for chelation therapy c. refer the family to child protective services d. schedule the toddler for a yearly rescreening
D
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? a. "I should remove the harness at night to allow my infant to stretch her legs." b. "I will need to adjust the straps on the harness once a week." c. "I should apply baby powder to my infant's skin twice daily." d. "I will place my infant's diaper under the harness straps."
D
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? a. increase anterior convexity of the lumbar spine b. increased curvature of the thoracic spine c. lateral flexion of the neck d. a unilateral rib hump
D
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan? a. administer ibuprofen to the child for a temperature greater than 38 degrees C (100.4 degrees F) b. assess the child's blood pressure every 8hr c. weigh the child weekly at a various times of the day d. initiate seizure precautions for the child
D - Hyponatremia places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? a. "your daddy will back at 7pm." b. "Your daddy will be back after he takes care of your brother." c. "Your daddy will be back in the morning" d. "Your daddy will be back after you eat."
D - Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.
A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? a. the toddler has a vocabulary of 25 words b. The toddler developed a mild rash following a recent varicella immunization c. the toddler's Moro reflex is absent d. the toddler received tobramycin during a hospitalization 2 weeks ago
D - The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? a. "Place the infant in a prone position to sleep." b. "Allow the infant to sleep on a large pillow." c. "Use a soft mattress in the infant's crib." d. "Give the infant a pacifier at bedtime."
D - The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will use a humidifier in my child's room at night." b. "I will give my child a cough suppressant Q6hrs if he has a cough." c. "I should avoid using a wet mop on my floors when I am cleaning." d. "I house keep my child indoors when I mow the yard."
D - The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.