question

During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?

answer

Stop the infusion immediately and notify the healthcare provider.

question

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?

answer

Prevent the return of oxygenated blood to the lungs.

question

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?

answer

Ribbon-like and brown.

question

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?

answer

Head and neck.

question

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?

answer

Store all toxic agents and medicines in locked cabinets.

question

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?

answer

Wash the wound gently with mild soap and water.

question

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?

answer

Children need to retain a sense of initiative without impinging on the rights and privileges of others.

question

The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?

answer

Pale bluish coloration of the toes

question

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?

answer

Risk for infection

question

A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?

answer

Nystatin (Mycostatin).

question

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?

answer

16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.

question

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?

answer

Do not give if the child has chickenpox, the flu, or any other viral illness.

question

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?

answer

Assess the child's respiratory status

question

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?

answer

Explain hospital schedules to the child, such as mealtimes.

question

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?

answer

Clubbed fingers.

question

Which behavior would the nurse expect a 2-year-old child to exhibit?

answer

Display possessiveness of toys.

question

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?

answer

Plenty of fluids should be consumed daily.

question

When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?

answer

Cessation of growth in a child that had been normal.

question

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?

answer

Serum BUN and creatinine levels

question

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

answer

A trial of human chorionic gonadotrophic hormone

question

When assessing a child with asthma, the nurse should expect intercostal retractions during

answer

inspiration

question

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?

answer

Use sunscreen when lying by the pool.

question

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?

answer

Explain that menarche varies and occurs between the ages of 12 and 18 years

question

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?

answer

Choking, coughing, and cyanosis.

question

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?

answer

consistently follow a set mealtime routine.

question

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?

answer

Administer tetanus toxoid booster.

question

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?

answer

Call the healthcare provider immediately if his nail beds appear blue.

question

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?

answer

Determine the child's pulse and respirations.

question

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?

answer

A 6-month-old with failure to thrive that has a closed anterior fontanel.

question

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?

answer

Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.

question

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?

answer

The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her.

question

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?

answer

Congenital heart disease.

question

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?

answer

12 to 15 months

question

To take the vital signs of a 4-month-old child, which order provides the most accurate results?

answer

Respiratory rate, heart rate, then rectal temperature

question

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?

answer

Eye exams.

question

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?

answer

Apply pressure and ice for bleeding while elevating and resting the extremity.

question

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?

answer

Record weight daily.

question

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?

answer

Have a bulb syringe readily available to remove secretions

question

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?

answer

Wash the hair and skin frequently with soap and hot water.

question

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?

answer

Administer aerosol therapy followed by postural drainage before meals.

question

Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?

answer

Tetracyclines.

question

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

answer

a tympanic measurement of temperature will provide the most accurate reading

question

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?

answer

Engage the child through drawing pictures.

question

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?

answer

Steatorrhea.

question

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?

answer

Use a happy-face/sad-face pain scale.

question

When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?

answer

Parental control should be consistent.

question

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?

answer

Administer PRN prescription of nifedipine (Procardia) sublingually.

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