During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
Stop the infusion immediately and notify the healthcare provider.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
Prevent the return of oxygenated blood to the lungs.
An 18-month-old is admitted to the hospital with possible Hirschsprung’s disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
Ribbon-like and brown.
A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified “Rule of Nines.” Which part of a child’s body is calculated as a larger percentage of total body surface than an adult’s?
Head and neck.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents and medicines in locked cabinets.
A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
Wash the wound gently with mild soap and water.
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, “Is this normal behavior for a child this age?” The nurse’s response should be based on which information?
Children need to retain a sense of initiative without impinging on the rights and privileges of others.
The nurse is assessing the neurovascular status of a child in Russell’s traction. Which finding should the nurse report to the healthcare provider?
Pale bluish coloration of the toes
The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
Risk for infection
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child?
16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.
The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he “has a tummy ache.” After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother’s question?
Do not give if the child has chickenpox, the flu, or any other viral illness.
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
Assess the child’s respiratory status
A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child’s adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes.
The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?
Which behavior would the nurse expect a 2-year-old child to exhibit?
Display possessiveness of toys.
A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child’s care?
Plenty of fluids should be consumed daily.
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
Cessation of growth in a child that had been normal.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate
A trial of human chorionic gonadotrophic hormone
When assessing a child with asthma, the nurse should expect intercostal retractions during
A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client’s teaching plan?
Use sunscreen when lying by the pool.
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies and occurs between the ages of 12 and 18 years
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
Choking, coughing, and cyanosis.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents’ teaching plan?
consistently follow a set mealtime routine.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent’s last tetanus toxoid booster was received eight years ago. What action should the nurse take?
Administer tetanus toxoid booster.
A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
Call the healthcare provider immediately if his nail beds appear blue.
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children’s vitamin pills. Which intervention should the nurse implement first?
Determine the child’s pulse and respirations.
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child’s fontanel finding should be reported to the healthcare provider?
A 6-month-old with failure to thrive that has a closed anterior fontanel.
The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
The oxygen hood is holding the baby’s oxygen level just at the point which is needed. You may stroke and talk to her.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease.
The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
12 to 15 months
To take the vital signs of a 4-month-old child, which order provides the most accurate results?
Respiratory rate, heart rate, then rectal temperature
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
Apply pressure and ice for bleeding while elevating and resting the extremity.
When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record weight daily.
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Have a bulb syringe readily available to remove secretions
A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?
Wash the hair and skin frequently with soap and hot water.
The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?
Administer aerosol therapy followed by postural drainage before meals.
Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?
The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child’s increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that
a tympanic measurement of temperature will provide the most accurate reading
The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?
Engage the child through drawing pictures.
A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?
To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?
Use a happy-face/sad-face pain scale.
When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?
Parental control should be consistent.
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?
Administer PRN prescription of nifedipine (Procardia) sublingually.
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