Peds Chapter 39; Pediatric Nursing Interventions and Skills

A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 mL/8 hr is being infused rather than the ordered amount of 300 mL/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours? a. 200 mL b. 300 mL c. 350 mL d. 400 mL

b. 300 mL

Which information should the nurse include in teaching parents how to care for a childs gastrostomy tube at home? a. Never turn the gastrostomy button. b. Clean around the insertion site daily with soap and water. c. Expect some leakage around the button. d. Remove the tube for cleaning once a week.

b. Clean around the insertion site daily with soap and water.

In preparing to give enemas until clear to a young child, the nurse should select: a. Tap water. b. Normal saline. c. Oil retention. d. Fleet solution.

b. Normal saline.

The nurse is going over discharge instructions with a mother whose 11-month-old child will be treated with antibiotics for their ear infection. Which of the following is the most accurate measuring device to use for liquid administration of medication? a. Medicine cups. b. Plastic syringe for po use. c. Teaspoons. d. Dropper.

b. Plastic syringe for po use.

Which of the following is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease? a. Teaching the parents how to irrigate the colostomy. b. Protecting the skin around the colostomy. c. Flushing the colostomy with a small amount of water. d. Applying elbow restraints to protect the colostomy site

b. Protecting the skin around the colostomy.

An 8-month-old infant is restrained to prevent interference with the intravenous infusion. The nurse should: a. Remove the restraints once a day to allow movement. b. Keep the restraints on constantly. c. Keep the restraints secure so the infant remains supine. d. Remove the restraints whenever possible.

d. Remove the restraints whenever possible.

Which is the preferred site for intramuscular injections in infants? a. Deltoid b. Dorsogluteal c. Rectus femoris d. Vastus lateralis

d. Vastus lateralis

All of the following techniques for medication administration to an infant are acceptable except: a. Adding the medication to the infant's 8 oz. bottle of formula. b. Allowing the infant to sit in the parent's lap during administration. c. Allowing the infant to suck the medication from an empty nipple. d. Inserting the needleless syringe into the side of the mouth while the infant nurses.

a. Adding the medication to the infant's 8 oz. bottle of formula.

Kimberly, age 3 years, has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102 F even though Kimberly had acetaminophen 2 hours ago. The nurses action should be based on knowing that: a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102 F indicates greater severity of illness. d. Fever over 102 F indicates a probable bacterial infection.

a. Fevers such as this are common with viral illnesses.

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her like before. The most appropriate nursing action is to: a. Grant her request. b. Explain why this is not possible. c. Identify an appropriate substitute for her mother. d. Offer to provide support to her during the procedure.

a. Grant her request.

When teaching a mother how to administer eyedrops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the upper eyelid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eyes surface

a. In the conjunctival sac that is formed when the lower lid is pulled down

An important nursing consideration when performing a bladder catheterization on a young boy is to: a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

b. Insert 2% lidocaine lubricant into the urethra.

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. The most appropriate way to collect small amounts of urine for these tests is to: a. Apply a urine-collection bag to the perineal area. b. Tape a small medicine cup to the inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe. d. Aspirate urine from a superabsorbent disposable diaper with a syringe.

c. Aspirate urine from cotton balls inside the diaper with a syringe.

Nursing considerations related to the administration of oxygen in an infant include to: a. Humidify the oxygen if the infant can tolerate it. b. Assess the infant to determine how much oxygen should be given. c. Ensure uninterrupted delivery of the appropriate oxygen concentration. d. Direct the oxygen flow so that it blows directly into the infants face in a hood.

c. Ensure uninterrupted delivery of the appropriate oxygen concentration.

The nurse must suction a child with a tracheostomy. Interventions should include: a. Encouraging the child to cough to raise the secretions before suctioning. b. Selecting a catheter with a diameter three-fourths as large as the diameter of the tracheostomy tube. c. Ensuring that each pass of the suction catheter take no longer than 5 seconds. d. Allowing the child to rest after every 5 times the suction catheter is passed.

c. Ensuring that each pass of the suction catheter take no longer than 5 seconds.

During gavage or gastrostomy feedings the nurse should: a. Push the formula gradually through the feeding tube. b. Use a parenteral burette to calibrate the feeding times. c. Give the infant a pacifier for sucking. d. Hang the feeding container from an IV pole

c. Give the infant a pacifier for sucking.

What nursing action is appropriate for specimen collection? a. Follow sterile technique for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen. c. Use Standard Precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family.

c. Use Standard Precautions when handling body fluids.

The nurse is caring for an unconscious child. Skin care should include: a. Avoiding use of pressure reduction on the bed. b. Massaging reddened bony prominences to prevent deep tissue damage. c. Using draw sheet to move child in bed to reduce friction and shearing injuries. d. Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

c. Using draw sheet to move child in bed to reduce friction and shearing injuries.

One of the major advantages of the recently developed skin-level devices for feeding children is that the button device: a. Does not clog as easily as other devices. b. Eliminates the need for frequent bubbling. c. Is less expensive than the traditional devices. d. Allows the child more mobility.

d. Allows the child more mobility.

The nurse is doing a prehospitalization orientation for a 7-year-old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is: a. Unnecessary. b. The surgeons responsibility. c. Too stressful for a young child. d. An appropriate part of the child's preparation.

d. An appropriate part of the child's preparation.

It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible can cause: a. Hyperthermia. b. Electrocution. c. Pressure necrosis. d. Burns under sensors.

d. Burns under sensors.

The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child, the nurse should: a. Ask the group, Who is Sam Hart? b. Call out to the group, Sam Hart? c. Ask each child, What's your name? d. Check the patient's identification name band.

d. Check the patients identification name band.

An appropriate intervention to encourage food and fluid intake in a hospitalized child is to: a. Force child to eat and drink to combat caloric losses. b. Discourage participation in noneating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever child expresses hunger.

d. Give high-quality foods and snacks whenever child expresses hunger.

The most frequently used site for bone marrow aspiration in children is the: a. Femur. b. Sternum. c. Tibia. d. Iliac crest.

d. Iliac crest.

To obtain a nasal washing for RSV in an infant, the nurse would optimally: a. Have the infant cough. b. Obtain mucus from the throat. c. Insert a suction catheter into the back of the throat. d. Instill 1-3 ml of sterile normal saline into a nostril

d. Instill 1-3 ml of sterile normal saline into a nostril

The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required (Select all that apply)? a. Catheterized urine collection b. Intravenous (IV) line insertion c. Oxygen administration d. Lumbar puncture e. Computed tomography (CT) scan with contrast

d. Lumbar puncture e. Computed tomography (CT) scan with contrast

When caring for a child with an intravenous infusion, the nurse should: a. Use a macrodropper to facilitate reaching the prescribed flow rate. b. Avoid restraining the child to prevent undue emotional stress. c. Change the insertion site every 24 hours. d. Observe the insertion site frequently for signs of infiltration

d. Observe the insertion site frequently for signs of infiltration

. Of the following choices for measuring 1 teaspoon of medication at home, the best device for the nurse to instruct the parent to use at home is the: a. Household soup spoon. b. Household measuring spoon. c. Measuring cup. d. Plastic disposable calibrated oral syringe.

d. Plastic disposable calibrated oral syringe.

When administering a gavage feeding to a school-age child, the nurse should: a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage. b. Check the placement of the tube by inserting 20 mL of sterile water. c. Administer feedings over 5 to 10 minutes. d. Position the child on the right side after administering the feeding.

d. Position the child on the right side after administering the feeding.

The best positioning technique for a lumbar puncture in a child is a: a. Side-lying position with neck flexion. b. Sitting position. c. Side-lying position with modified neck extension. d. Side-lying position, head flexed with knees to chest.

d. Side-lying position, head flexed with knees to chest.

Total parenteral nutrition (TPN) is infused by way of a central intravenous line because: a. Other medications need to be infused with the TPN. b. Several attempts to administer it peripherally have probably occurred. c. There is less risk of infection. d. The glucose in the solution is irritating to the smaller veins

d. The glucose in the solution is irritating to the smaller veins

In order to protect the pouch, a young child with an ostomy may need to: a. Wear a loose-fitting one-piece outfit. b. Begin toilet training at a later than usual age. c. Limit activity to avoid skin damage. d. Use elbow restraints at all times.

a. Wear a loose-fitting one-piece outfit.

The angle for injection for a subcutaneous medication is typically 90 degrees a. True b. False

a. True

The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should: a. Wash hands thoroughly. b. Check the gloves for leaks. c. Rinse gloves in disinfectant solution. d. Apply new gloves before touching the next patient.

a. Wash hands thoroughly.

When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administering the medication with a syringe (without needle) placed along the side of the infants tongue b. Administering the medication as rapidly as possible with the infant securely restrained c. Mixing the medication with the infants regular formula or juice and administering by bottle d. Keeping the child upright with the nasal passages blocked for a minute after administration

a. Administering the medication with a syringe (without needle) placed along the side of the infants tongue

Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to: a. Allow her to wear her underpants. b. Discuss with her mother why this is important to Katie. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.

a. Allow her to wear her underpants.

Which of the following examples of a child's food intake is the best example of adequate documentation? a. Child ate about a cup of cereal with ½ cup of milk. b. Child ate an adequate breakfast. c. Child ate 80% of the breakfast served. d. Parent states that child ate an adequate breakfast.

a. Child ate about a cup of cereal with ½ cup of milk.

The nurse is teaching a mother how to perform chest physiotherapy and postural drainage on her 3-year-old child, who has cystic fibrosis. To enable the mother to perform percussion, the nurse should instruct her to: a. Cover the skin with a shirt or gown before percussing. b. Strike the chest wall with a flat-hand position. c. Percuss over the entire trunk anteriorly and posteriorly. d. Percuss before positioning for postural drainage.

a. Cover the skin with a shirt or gown before percussing.

The nurse gives an injection in a patients room. What should the nurse do with the needle for disposal? a. Dispose of syringe and needle in a rigid, puncture-resistant container in patients room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patients room. c. Cap needle immediately after giving injection and dispose of in proper container. d. Cap needle, break from syringe, and dispose of in proper container.

a. Dispose of syringe and needle in a rigid, puncture-resistant container in patients room.

The nurse is caring for an 8-year-old child who is on fall precautions. Which of the following interventions would be appropriate to include in the child's plan of care? Select all that apply. a. Keep the call light and tray table with desired items within reach. b. Keep the bed in the highest position with the two side rails up. c. Keep personal belongings and clutter contained in one area of the floor. d. Ensure that the patient has an appropriate-size gown and nonskid footwear. e. Keep lights on at all times, including dim lights while sleeping.

a. Keep the call light and tray table with desired items within reach. d. Ensure that the patient has an appropriate-size gown and nonskid footwear. e. Keep lights on at all times, including dim lights while sleeping.

The advantages of the ventrogluteal muscle as an injection site in young children include which of the following (Select all that apply)? a. Less painful than vastus lateralis b. Free of important nerves and vascular structures c. Cannot be used when child reaches a weight of 20 pounds d. Increased subcutaneous fat, which increases drug absorption e. Easily identified by major landmarks

a. Less painful than vastus lateralis b. Free of important nerves and vascular structures e. Easily identified by major landmarks

An increased heart rate, increased respiratory rate, and increased blood pressure in the immediate postoperative period of a young child would most likely indicate: a. Pain. b. Infection. c. Shock. d. Increased intracranial pressure.

a. Pain.

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurses best action is to: a. Prepare child for conscious sedation during the test. b. Set up a tray with equipment the same size as for adults. c. Reassure the parents that the test is simple, painless, and risk free. d. Apply EMLA to puncture site 15 minutes before procedure.

a. Prepare child for conscious sedation during the test.

A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats.

a. Request these favorite foods for him.

A 2-month-old infant is admitted to the hospital with probable respiratory syncytial virus (RSV). The infant's mother is 17 years old, single, and lives with her parents. The father of the infant lives with his parents. Who signs the informed consent for the infant? a. The infant's mother b. The maternal grandparents c. The paternal grandparents d. Both maternal and paternal grandparents

a. The infant's mother

The needle length needed for intramuscular injections will vary depending on the amount of subcutaneous fat a child has. The needle length must be long enough to penetrate the subcutaneous fat and deposit the medication into the body of the muscle. a. True b. False

a. True

When administering a medication via the rectum, if the dose ordered is not available, the suppository should be cut lengthwise and inserted with the apex first a. True b. False

a. True

When administering eye drops and eye ointment, the eye drops should be administered first, followed by the eye ointment 3 minutes later. a. True b. False

a. True

What is critical information for the nurse to incorporate into her care when using restraints on a child? a. Use the least restrictive type of restraint. b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin.

a. Use the least restrictive type of restraint.

A nurse is caring for a child in Droplet Precautions. Which instructions should the nurse give to the unlicensed assistive personnel caring for this child (Select all that apply)? a. Wear gloves when entering the room. b. Wear an isolation gown when entering the room. c. Place the child in a special air handling and ventilation room. d. A mask should be worn only when holding the child. e. Wash your hands upon exiting the room.

a. Wear gloves when entering the room. b. Wear an isolation gown when entering the room. e. Wash your hands upon exiting the room.

Using knowledge of child development, the best approach when preparing a toddler for a procedure is to: a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for the teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.

b. Demonstrate the procedure on a doll.

After cleft lip surgery, which of the following would be most appropriate to use to protect the operative site: a. Arm and leg restraints. b. Elbow restraints. c. A jacket restraint. d. A mummy restraint.

b. Elbow restraints.

Guidelines for intramuscular administration of medication in school-age children include to: a. Inject medication as rapidly as possible. b. Insert the needle quickly, using a dartlike motion. c. Penetrate the skin immediately after cleansing the site, before skin has dried. d. Have the child stand, if possible, and if he or she is cooperative.

b. Insert the needle quickly, using a dartlike motion.

The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next? a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

b. Keep arm extended, and apply pressure to the site for a few minutes.

Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy? a. Set the oxygen flow rate at less than 6 L/min. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour.

b. Make sure the mask fits properly.

A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this: a. Is unsafe. b. May help the child relax. c. Is against hospital policy. d. Is unnecessary because of the childs age.

b. May help the child relax.

To avoid the complication of necrotizing osteochondritis when performing infant heel puncture, the puncture should be: a. No deeper than 4 mm and on the inner aspect of the heel. b. No deeper than 2 mm and on the outer aspect of the heel. c. No deeper than 2 mm and on the inner aspect of the heel. d. No deeper than 4 mm and on the outer aspect of the heel.

b. No deeper than 2 mm and on the outer aspect of the heel.

A 3-year-old with cystic fibrosis has a skin-level feeding device and is being cared for at home. The mother calls the skin specialist and says the skin around the skin-level device is moist and beefy red but there is no evidence of foul odor, bleeding, or formula leakage. The nurse is aware this finding is: a. A skin infection. b. Normal granulation tissue. c. A reason to change the skin-level device. d. A reason to discontinue using this device.

b. Normal granulation tissue.

A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. What best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.

b. Rapid venous access is not possible.

The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include: a. Planning for a short teaching session of about 30 minutes. b. Telling the child that procedures are never a form of punishment. c. Keeping equipment out of the childs view. d. Using correct scientific and medical terminology in explanations.

b. Telling the child that procedures are never a form of punishment.

What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? a. You must hold still or Ill have someone hold you down. This is not going to hurt. b. This will hurt like a pinch. Ill get someone to help hold your arm still so it will be over fast and hurt less. c. Be a big boy and hold still. This will be over in just a second. d. I'm sending your mother out so she wont be scared. You are big, so hold still and this will be over soon.

b. This will hurt like a pinch. Ill get someone to help hold your arm still so it will be over fast and hurt less.

An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with: a. A bottle of formula or milk. b. Any food the child is going to eat. c. A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. d. Large amounts of water to dilute medication sufficiently.

c. A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.

A 7-year-old child is being prepared for bowel surgery. Which of the following is the most appropriate to use for bowel cleansing in this child: a. A pediatric Fleet enema. b. A commercially prepared hypertonic enema solution. c. An oral polyethylene glycol-electrolyte solution. d. Plain water enemas.

c. An oral polyethylene glycol-electrolyte solution.

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics: a. May cause malignant hyperthermia. b. May cause febrile seizures. c. Are of no value in treating hyperthermia. d. Are of limited value in treating hyperthermia.

c. Are of no value in treating hyperthermia.

In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is: a. Apnea. b. Bradycardia. c. Muscle rigidity. d. Decreased blood pressure.

c. Muscle rigidity.

Which of the following routes is the preferred method of medication administration in children? a. Intravenous b. Intramuscular c. Oral d. Otic

c. Oral

A nurse must do a venipuncture on a 6-year-old child. An important consideration in providing a traumatic care is to: a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain the child only as needed to perform venipuncture safely. d. Show the child equipment to be used before procedure.

c. Restrain the child only as needed to perform venipuncture safely.

Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should: a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.

c. Stop the bath if the child begins to chill.

The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should a. Ask him to be quieter. b. Have his mother tell him to relax. c. Tell him it is okay to cry and scream. d. Suggest that he talk to his mother instead of crying.

c. Tell him it is okay to cry and scream.

Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). Which of the following is essential information for the parents to receive? a. The parents should be taught how to verify placement of the G-tube before each feeding. b. The parents should be taught how to irrigate the G-tube before each feed. c. The parents should be taught to place the infant on their right side after feedings. d. The parents should be taught if beefy red tissue develops around the G-tube site that must be reported to the practitioner.

c. The parents should be taught to place the infant on their right side after feedings.

What should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of7 years or older is required for a consent to be considered informed

c. The risks and benefits of a procedure are part of the consent process.

A 4-year-old attending daycare came home with a fever and runny nose. The child is being cared for at home. What is the principal reason for treating the fever in this child? a. Avoid the development of life-threatening complications. b. To prevent a bacterial infection from developing. c. To relieve discomfort. d. To prevent a prolonged illness.

c. To relieve discomfort.

The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which procedure is recommended to facilitate this? a. Apply cool, moist compresses. b. Apply a tourniquet to the ankle. c. Elevate the foot for 5 minutes. d. Wrap foot in a warm washcloth.

d. Wrap foot in a warm washcloth.