Peds Final Exam NCLEX (all)
366. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula
1. Weighing the diapers
422. . Atropine sulfate, 0.6 mg intramuscularly, is prescribed for a child preoperatively. The nurse has determined that the dose prescribed is safe and prepares to administer how many milliliters to the child? Fill in the blank (refer to figure). Figure is a med label that says 0.4mg = 1mL
1.5 mL
The ventrogluteal muscle is safe for intramuscular injections for children older than...
13 months
321. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1. Maintain the child in a semiprivate room. 2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask. 5. Apply firm pressure to a needle-stick area for at least 10 minutes
2, 3, 4
301. The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults.
2, 3, 6 (Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults)
173. The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The mother reports that the child is having intermittent episodes of diarrhea. 4. The mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The mother reports that the child has recently been exposed to an infectious disease.
2, 5
402. The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 6. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.
2, 5, 6
368. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and activity is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."
2. "I can apply lotion or powder to the incision if it is itchy."
354. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. Side or prone 2. Back or prone 3. Stomach with the face turned 4. Back rather than on the stomach
4. Back rather than on the stomach
384. A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia
4. Bradycardia
340. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools
4. Bright red blood and mucus in the stools (described as currant jelly-like stools)
163. A 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess our children need to understand what the word hot means." 3. "We will be sure that the children stay in their rooms when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen."
1. "We will be sure not to leave hot liquids unattended."
362. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing
3. Tachycardia (early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress)
381. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids
1, 2, 3, 4 (Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.)
392. The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.
1, 3, 5
361. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask, gown, and gloves when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
1, 3, 6 (The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.)
351. A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Provide a soft diet. 2. Position the child on the left side. 3. Administer an antihistamine twice daily. 4. Irrigate the right ear with normal saline every 8 hours. 5. Administer ibuprofen for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.
1, 5, 6 (a soft diet avoids pain with chewing, position on affected side for drainage, antihistamines not related, irrigation will further inflame area, ibuprofen helps manage pain, and antibiotics should be taken as prescribed)
310. The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L/minute. 5. Provide a high-calorie, high-protein diet. 6. Give meperidine, 25 mg intravenously, every 4 hours for pain
1, 6 (Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.)
Parents report their 3-year-old child appears restless at night and frequently scratches her anal area. What action by the nurse is best? 1. Educate parents on the cellophane tape test. 2. Review hygiene practices with the parents. 3. Suggest the child sleep only in pajama tops. 4. Ask parents to bring in a stool sample.
1. Educate parents on the cellophane tape test. (pinworm dx)
157. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.
1. Encourage the child's parents to stay with the child.
295. The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1. Fine grayish red lines 2. Purple-colored lesions 3. Thick, honey-colored crusts 4. Clusters of fluid-filled vesicles
1. Fine grayish red lines
348. The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? 1. Frequent swallowing 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure
1. Frequent swallowing (Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding.)
316. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 10 9 /L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1. Initiate bleeding precautions. 2. Monitor closely for signs of infection. 3. Monitor the temperature every 4 hours. 4. Initiate protective isolation precautions.
1. Initiate bleeding precautions. (for any count less that 50k)
383. The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow
1. Meningitis (positive Kernig's sign)
342. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1. Turn the child to the side. 2. Administer the prescribed antiemetic. 3. Maintain NPO (nothing by mouth) status. 4. Notify the primary health care provider (PHCP).
1. Turn the child to the side. (all are correct, but this is the first action important to prevent aspiration)
317. The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. Vomiting 2. Bulging anterior fontanel 3. Increasing head circumference 4. Complaints of a frontal headache
1. Vomiting (vomiting will be excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center)
395. A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? 1. "The cast may feel warm as the cast dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."
2. "I can use lotion or powder around the cast edges to relieve itching." (lotions and powders should NOT be used bc they can become caked, leading to further irritation and skin breakdown)
372. The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis? 1. "His pediatrician said his kidneys are working well." 2. "I noticed his urine was the color of cola lately." 3. "I'm so glad they didn't find any protein in his urine." 4. "The nurse who admitted my child said his blood pressure was low."
2. "I noticed his urine was the color of cola lately."
318. A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? 1. Lumbar puncture showing no blast cells 2. Bone marrow biopsy showing blast cells 3. Platelet count of 350,000 mm3 (350 × 10 9 /L) 4. White blood cell count 4500 mm3 (4.5 × 10 9 /L)
2. Bone marrow biopsy showing blast cells
352. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats per minute 4. Respirations of 18 breaths per minute
2. Decreased wheezing (Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving.; warm dry skin shows improvement, and both of those vitals are normal for a 10yo)
161. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Notify the pediatrician. 4. Elevate the head of the bed to 90 degrees.
2. Document the finding. (normal finding)
160. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the pediatrician. 4. Reassess the respiratory rate in 15 minutes
2. Document the findings. (The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths per minute. The normal apical heart rate is 90 to 130 beats per minute, and the average blood pressure is 90/56 mm Hg; 35 bpm is a normal rr)
363. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer
4. Anti-streptolysin O titer
373. The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? 1. Hypertension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine
2. Generalized edema
7. The parent of a toddler calls the nurse, asking about croup. What is a distinguishing manifestation of spasmodic croup? 1. Wheezing is heard audibly. 2. It has a harsh, barky cough. 3. It is bacterial in nature. 4. The child has a high fever.
2. It has a harsh, barky cough.
360. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a private room. 3. Leave the infant in the present room, because RSV is not contagious. 4. Inform the staff that using standard precautions is all that is necessary when caring for the child.
2. Move the infant to a private room. (highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. Use of contact, droplet, and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves, gown, and a mask should be done to prevent transmission.)
338. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile
2. Projectile vomiting (Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.)
345. The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is MOST significant to review? 1. Creatinine level 2. Prothrombin time 3. Sedimentation rate 4. Blood urea nitrogen level
2. Prothrombin time (postop bleeding is critical concern)
391. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.
2. Reposition the infant frequently. (prevent pressure ulcers on head)
346. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? 1. Supine 2. Side-lying 3. High-Fowler's 4. Trendelenburg's
2. Side-lying
347. After a tonsillectomy, the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question? 1. Monitor for bleeding. 2. Suction every 2 hours. 3. Give no milk or milk products. 4. Give clear, cool liquids when awake and alert.
2. Suction every 2 hours. (equipment should be available, but is not performed unless there is an airway obstruction bc of risk of trauma to surgical site)
350. The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? 1. The child has difficulty hearing. 2. The child consistently tilts the head to see. 3. The child does not respond when spoken to. 4. The child consistently turns the head to hear.
2. The child consistently tilts the head to see. ("cross eyed"-Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception.)
356. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting herself or himself with the hands and arms.
2. The child is leaning forward, with the chin thrust out. (epiglottitis causes tachycardia and high fever, so 1 and 3 are wrong.)
169. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse.
3, 5, 6
331. The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
3, 6
359. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."
3. "Antibiotics are not indicated unless a bacterial infection is present." (can be viral or bacterial; other options are all wronggggg)
414. . The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment? 1. "Has your child had difficulty urinating?" 2. "Has your child been exposed to anyone with chickenpox?" 3. "Has any family member had a sore throat within the past few weeks?" 4. "Has any family member had a gastrointestinal disorder in the past few weeks?"
3. "Has any family member had a sore throat within the past few weeks?" (Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract.)
398. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? 1. "I will encourage my child to perform prescribed exercises." 2. "I will have my child wear soft fabric clothing under the brace." 3. "I should apply lotion under the brace to prevent skin breakdown." 4. "I should avoid the use of powder because it will cake under the brace."
3. "I should apply lotion under the brace to prevent skin breakdown."
416. The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1. "I should cuddle my child after giving the medication." 2. "I can give my child a frozen juice bar after he swallows the medication." 3. "I should mix the medication in the baby food and give it when I feed my child." 4. "If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw."
3. "I should mix the medication in the baby food and give it when I feed my child."
344. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye as prescribed." 3. "It is okay to share towels and washcloths." 4. "I need to give the eye drops as prescribed."
3. "It is okay to share towels and washcloths."
297. The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1. "It is extremely contagious." 2. "It is most common in humid weather." 3. "Lesions most often are located on the arms and chest." 4. "It might show up in an area of broken skin, such as an insect bite."
3. "Lesions most often are located on the arms and chest." (Impetigo is a contagious bacterial infection of the skin caused by βhemolytic streptococci or staphylococci, or both. Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities.)
319. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1. "I have a vase in the utility room, and I will get it for you." 2. "I will get the vase and wash it well before you put the flowers in it." 3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."
3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."
419. Sulfisoxazole, 1 g orally twice daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent? 1. ½ tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets
3. 2 tablets
418. A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg/day, and the client's weight is 7.2 kg. The pediatrician prescribes the digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer to the child at each dose? 1. 12.6 mcg 2. 21.4 mcg 3. 28.8 mcg 4. 32.2 mcg
3. 28.8 mcg
382. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A chronic disability characterized by impaired muscle movement and posture 4. A congenital condition that results in moderate to severe intellectual disabilities
3. A chronic disability characterized by impaired muscle movement and posture
367. The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Activity intolerance 4. Gastrointestinal disturbances
3. Activity intolerance (Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of activity intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted but is not specific to this type of disorder alone)
294. The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? 1. Skin turgor 2. Level of edema at burn site 3. Adequacy of capillary filling 4. Amount of fluid tolerated in 24 hours
3. Adequacy of capillary filling
389. A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels
3. Cloudy CSF, elevated protein, and decreased glucose levels
364. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin
3. Conjunctival hyperemia (In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.)
170. An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.
4. Apply a cold pack to the injection site.
324. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.
3. Encourage the child to drink liquids.
333. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? Hint: avoid aspiration risk 1. Prone position 2. On the stomach 3. Left lateral position 4. Right lateral position
3. Left lateral position (After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position, because these positions can cause rubbing of the surgical site on the mattress)
371. Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect
3. Patent ductus arteriosus (A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure.)
386. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extre
3. Rigid extension and pronation of the arms and legs
369. A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"
4. "Did the child have a sore throat or fever within the last 2 months?"
379. Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? 1. "Did your child fall off a bike onto the handlebars?" 2. "Has the child had persistent nausea and vomiting?" 3. "Has the child been itching or had a rash anytime in the last week?" 4. "Has the child had a sore throat or a throat infection in the last few weeks?"
4. "Has the child had a sore throat or a throat infection in the last few weeks?"
365. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "If more than 1 dose is missed, I will call the pediatrician." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."
4. "If my child vomits after medication administration, I will repeat the dose."
411. The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."
4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks." (The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase.)
417. A pediatrician's prescription reads "ampicillin sodium 125 mg IV every 6 hours." The medication label reads "when reconstituted with 7.4 mL of bacteriostatic water, the final concentration is 1 g/7.4 mL." The nurse prepares to draw up how many milliliters to administer 1 dose? 1. 1.1 mL 2. 0.54 mL 3. 7.425 mL 4. 0.925 mL
4. 0.925 mL
420. Penicillin G procaine, 1,000,000 units IM (intramuscularly), is prescribed for an adolescent with an infection. The medication label reads "1,200,000 units per 2 mL." The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the adolescent? Round answer to the nearest tenth position. 1. 0.8 mL 2. 1.2 mL 3. 1.4 mL 4. 1.7 mL
4. 1.7 mL
A parent asks the nurse how she will know whether her child has fifth disease. The nurse should advise the parent to be alert for which manifestation? 1. Bull's-eye rash at the site of a tick bite 2. Lesions in various stages of development on the trunk 3. Maculopapular rash on the trunk that lasts for 2 days 4. Bright red rash on the cheeks that looks like slapped cheeks
4. Bright red rash on the cheeks that looks like slapped cheeks (Fifth disease manifests with an intense, fiery red, edematous rash on the cheeks, which gives a "slapped cheek" appearance.)
394. A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? 1. Ensure that all ropes are outside the pulleys. 2. Ensure that the weights are resting lightly on the floor. 3. Restrict diversional and play activities until the child is out of traction. 4. Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.
4. Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.
166. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book
4. Crayons and a coloring book
323. A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.
4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.
353. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side
4. Encourage the child to lie on the right side (Splinting of the affected side by lying on that side may decrease discomfort.)
306. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? 1. Stress 2. Trauma 3. Infection 4. Fluid Overload
4. Fluid Overload (Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.)
332. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools
4. Foul-smelling ribbon-like stools
326. An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness
4. Fruity breath odor and decreasing level of consciousness
357. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the pediatrician and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.
4. Let the mother hold the child and direct the cool mist over the child's face.
390. The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
397. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims' position. 4. Notify the primary health care provider (PHCP).
4. Notify the primary health care provider (PHCP). (Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome.)
393. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? 1. Administer an analgesic. 2. Release the skin traction. 3. Apply ice to the extremity. 4. Notify the primary health care provider (PHCP).
4. Notify the primary health care provider (PHCP). (sign of compartment syndrome; immediately needs to be reported to provider to confirm, then surgery)
329. The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.
4. Remove excess clothing and blankets from the child.
412. . The nurse caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots (these appear 2 days before the rash). On the basis of this documentation, which observation is expected? 1. Pinpoint petechiae noted on both legs 2. Whitish vesicles located across the chest 3. Petechiae spots that are reddish and pinpoint on the soft palate 4. Small, blue-white spots with a red base found on the buccal mucosa
4. Small, blue-white spots with a red base found on the buccal mucosa (last 3 days, then slough off)
388. The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen
4. Suctioning equipment and oxygen (Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside)
335. The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings. 2. Burp the infant less frequently during feedings. 3. Thin the feedings by adding water to the formula. 4. Thicken the feedings by adding rice cereal to the formula.
4. Thicken the feedings by adding rice cereal to the formula.
421.. The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis
4. Vastus lateralis
370. A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing
4. When drawing blood for electrolyte level testing (used for periods of stress bc Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands)
300. The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area
4. White sacs attached to the hair shafts in the occipital area
has been treated with a range of antibiotics, and it is the most common disorder treated with antibiotics in the ambulatory setting
AOM (acute otitis media)
What should be included in health teaching to prevent Lyme disease? (no vaccine is available, antibiotics can treat but cannot prevent) Use insect repellant with ____________ in heavily wooded areas
DEET (also note the bull's eye rash at the site of a tick bite is a hallmark sign of Lyme disease)
______ should be worn when changing diapers, soiled clothing, or linens involving gastroenteritis. They do not need to be worn for interactions that do not involve contact with secretions
Gloves
manifests as a maculopapular rash on the trunk that can last for hours or up to 2 days.
Roseola
Which muscle should the nurse select to give a 6-month-old infant an intramuscular injection?
Vastus Lateralis (not located near any vital nerves or blood vessels. It is the best choice for intramuscular injections for children younger than 3 years of age)
What is the most important action to prevent the spread of gastroenteritis in a daycare setting?
frequent handwashing
account for a significant number of deaths from aspiration every year.
latex balloons
For volumes of 5 mL or less, an ________ designed for oral medication administration only should be used. Measuring cups would be too large. A household teaspoon may or may not be accurate and the AAP recommends metric-only measuring devices.
oral syringe (calibrated)
T/F: The deltoid muscle is not used for intramuscular injections in young children.
true
manifested as lesions in various stages of development—macule, papule, then vesicle, first appearing on the trunk and scalp.
varicella
The dorsogluteal muscle does not develop until a child has been...
walking for at least 1 year
