a nurse is planning care for a child who has severe diarrhea. which of the
following actions is the nurse priority?
A. Introduce a regular diet
B.
... [Show More] Rehydrate
C. Maintain fluid therapy
D. Assess fluid balance
(Assess first the other three are interventions, before u intervene you have
to assess how much fluid imbalance. Check for labs results because it will
tell you what kind of fluid is to be given and how much fluid to be replaced.
Priority is assessment first)
A nurse is caring for a toddler who’s parent states that the child has a mass in his
abdominal area and his urine is a pink color. Which of the following actions is the
nurse’s priority?
A. Schedule the child for an abdominal ultrasound
B. Instruct the parent to avoid pressing on the abdominal area
C. Determine if the child is having pain
D. Obtain a urine specimen for a urinalysis
A nurse is caring for a child who has acute glomerulonephritis. Which of the
following actions is the nurse’s priority?
A. Place the child on a no salt added diet
B. Check the Childs weight daily
C. Educate the parents about potential complications
D. Maintain a saline lock (IV access that is attached to any fluids. For
emergency)
(inflammation of the kidneys caused by group A beta hemolytic streptococcus,
infection. Fluid or fluid retention. Patient with kidney problems affect blood
pressure -> High blood pressure because of fluid retention. Salt increases high
blood pressure. Lower the salt intake of this patient)
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis.
Which of the following is the nurse’s priority?
A. Administer antibiotics when available
B. Reduce environmental stimuli (because of increase of ICP and can cause
seizures)
C. Document intake and outputD. Maintain seizure precautions
A nurse is collecting data from an adolescent. Which of the following represents
the greatest risk for suicide?
A. Availability of firearms
B. Family conflict
C. Homosexuality
D. Active psychiatric disorder (Mark, mental problems, patients mind is
unstable)
A nurse is collecting data from an infant who has otitis media (middle ear
infection). The nurse should expect which of the following findings?
A. Tugging on the affected ear lobe
B. Bluish green discharge from the ear canal (there’s usually no discharge,
discharge only comes out if there’s opening in the ear drum)
C. Increase in appetite (decrease in appetite)
D. Erythema and edema of the affected auricle (usually no redness in the
affected auricle)
(otitis externa: infection of the outer ear)
A nurse is reinforcing reaching with a parent of a 1 month old infant who is to
undergo the initial surgery to treat Hirschsprung’s disease (a ganglionic
megacolon, part of the colon isn’t connected to the nerves or not functioning, so
there will be an increase size of the colon and stool gets stuck in there). Which of
the following statements should indicate to the nurse that the parent
understanding the goal of surgery?
A. “I’m glad that the ostomy is only temporary “ (1st there going to cut the
nonfunctioning of the colon, and then apply temporary colostomy, after a
couple of months they will suture it together)
B. “I’m glad my child will have normal bowel movements now”
C. “I want to learn how to use the feeding tube as soon as possible”
D. “the operation will straighten out the kink in the intestine”
A nurse is caring for an infant who is 1 day postoperative following surgical repair
of a cleft lip. Which of the following actions should the nurse take?
A. Apply an antibiotic ointment to the suture site
B. Clear oral secretions using a bulb syringeC. Feed the infant using a spoon
D. Position the infant on her abdomen
A nurse is reinforcing discharge instructions with a parent of a child who has cystic
fibrosis. Which of the following statements by the parent indicates an
understanding of the teaching?
A. “I will make sure my child washes her hands before eating”
B. “I will restrict the amount of salt in my child’s meal”
C. “I will put my child in daycare to ensure that she socializes with other
children”
D. “I will provide low fat meals for my child
A nurse working at a clinic speaks on the telephone with a parent of a 2-monthold infant. The parent tells the nurse that the infant has projectile vomiting
followed by hunger after meals. Which of the following response by the nurse is
appropriate?
A. “Bring your infant into the clinic today to be seen”
B. “Burp your child more frequently during feedings”
C. “Give your infant an oral rehydrating solution”
D. “You might want to try switching to different formula”
A nurse is caring for a 4 year old child who is 2 days postoperative following the
insertion of a ventriculoperitoneal shunt. Which of the following findings should
the nurse identify as the priority . (causes icp hydrocephalus)
A. lethargy (high pitched cry, respiratory changes, bradycardia, wide pulse
pressure, irritability)
B. lying flat on the unaffected side
C. respiratory rate 20/min
D. urine output 50 mL in 2hr
a nurse is caring for a child following an open reduction and internal fixation of a
fractured femur and application of a cast. The cast has a window cut in it for
viewing of the incision. Which of the following actions should the nurse take first?
A. Remove the window and view the incision
B. Turn the client so the cast will dry on all sides
C. Medicate the client for painD. Perform neurovascular checks of the affected extremity (check for infection,
color, capillary refill, redness)
A nurse is an urgent care clinic is assisting with the care of a toddler who ingested
30 tablets of aspirin. Which of the following substances should the nurse
administer to the toddler?
A. Activated charcoal (can work with toxin, poison. Given through ng tube
absorbs toxins)
B. Acetylcysteine (antidote for acetaminophen)
C. A chelating agent (usually used for iron)
D. Digoxin immune FAB
A nurse is caring for a 3 year old client who has persistent otitis media. To help
identify contributing factors, the nurse should ask the parents which of the
following questions?
A. Has your daughter been drinking 6 glasses of water a day
B. Does anyone smoke in the same house as your daughter? (smoking can
cause irritation, cause mucus in respiratory and causes otitis media?) (otitis
media is purulent color)
C. Does your daughter get water in her ears when you bathe her? (otitis
externa, bluish green color)
D. Has your daughter had a lot of earwax in her ears over the last month?
A nurse is collecting data from a 2 year old toddler who has AIDS. The nurse
should inspect inside the toddler mouth for which of the following opportunistic
infections (fungus infections is usually opportunistic infections)?
A. Candidiasis (also called oral thrush)
B. Gingivitis
C. Canker sores
D. Koplik spots (measles, rubella)
A nurse is caring for a 4 year old child who has dehydration. Which of the
following findings should the nurse identify as the priority?
A. Blood glucose 110 mg/dL
B. Potassium 2.5 mEq/L
C. Sodium 142 mEq/L
D. Urine specific gravity 1.025A nurse is caring for a child who Is postoperative following the insertion of a
ventriculorperitoneal shunt. The nurse should place the child in which of the
following positions?
A. On the nonoperative side
B. A 45 deg head elevation
C. Prone
D. Supine
A nurse is caring for an infant who is dehydrated and requires IV therapy. The
nurse should monitor the infant response to therapy by performing which of the
following actions?
A. weighing the infants at the same time everyday
B. Taking the infants vital signs every 2 hr.
C. Measuring the infants head circumference twice per day
D. Counting the number of wet diapers every shift
A nurse is caring for a preschool age child who has croup. Which of the following
findings should the nurse report to the provider?
A. Barky cough
B. Paroxysmal attacks of laryngeal spasm at night
C. Hoarseness
D. Drooling (that could mean it can mean there’s an epiglottitis causes
obstruction of the airway)
A nurse is collecting data from an infant who has hypertrophic pyloric stenosis.
Which of the following findings should the nurse expect?
A. Projectile vomiting
B. Bile colored vomit
C. Absent bowel sounds
D. Fever
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of
the following instructions should the nurse give the child for this examination?
A. Lie prone on the examination table
B. Touch your chin to your chest and then look up at the ceiling
C. Turn to the side and remain in a relaxed positionD. Bend forward from the waist with your head and arms downward
A nurse is collecting data from an infact. Which of the following sites is the most
reliable location to check the infats pulse ?
A. Carotid
B. Apical
C. Dorsalis pedis
D. Temporal
A nurse is reinforcing teaching with a parent of a child who has eczema. Which of
th following instructions should the nurse include in the teaching
A. Apply a cool wet compress to the affected area
B. Launder clothing with fabric softener
C. Give bubble baths every day
D. Use a wool gloves in the winter time
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the
following actions should the nurse take?
A. Administer opioids on a schedule (Nsaids)
B. Encourage the child to take daytime naps
C. Apply cool compresses for 20 mins every hour
D. Maintain night splints to the affected joint
A nurse is reinforcing teaching with a parent of an 8-year-old child who has a
fracture of the epiphyseal plate. Which of the following statements should the
nurse include in the teaching.
A. Fractures in a child take longer to heal than fractures in an adult
B. Normal bone growth can be affected by the fracture
C. Bone marrow can be lost through the fracture
D. Your child will need to increase his calcium intake to 3,000 milligrams daily
A nurse is collecting data from an 8 month old infant who has increased
intracranial pressure (ICP) which of the following manifestations should the nurse
expect?
A. Insomnia (tired sleepy)B. Bulging fontanel
C. Low pitched cry (high pitched)
D. Positive babinski reflex
A nurse is caring for a school age child who has a fracture to the right femur.
Which of the following findings is the nurse priority?
A. 2+ right pedal pulse
B. respiratory rate 24/min
C. capillary refill less than 2 seconds
D. tingling in the right foot
A nurse is caring for a child who has atopic dermatitis. Which of the following
findings should the nurse expect?
A. Nonpruritic erythematous papulse
B. Rash with thick skin
C. Maculopapular lesions between fingers and toes
D. Inflamed area with white exudate
A nurse is assisting with the care of a school age child who has respiratory failure
due to pneumonia. Which of the following positons should the nurse encourage
to allow maximal lung expansions?
A. Prone
B. Supine
C. Side lying
D. Upright (orthopnic positon, semi fowler, high fowler)
A nurse in a provider’s office is reinforcing teaching with a parent of a school age
child who has pediculosis capitis. Which of the following instructions should the
nurse include in the teaching?
A. Wash all bed linens and dry them in a dryer for at least 20 min
B. Apply permethrin cream twice daily
C. Apply an antifungal treatment ointment once every day
D. Ensure that family pets are treated within 10 days
A nurse is reinforcing teaching with the mother of an infant who has oral
candidiasis and is breastfeeding which of the following instructions should the
nurse include in the teaching?A. Wash hands prior to each breastfeeding
B. Swab the infants mouth with salt water twice daily
C. Change to formula feeding with a bottle
D. Hand wash pacifier in warm soapy water each day
A nurse is caring for a school age child who has mild persistent asthma. Which
of the following findings should the nurse expect? (select all the apply)
A. Symptoms are continual throughout the day
B. Daytime symtoms occur more than twice per week
C. Nighttime symptoms occur approximately twice per month
D. Minor limitations occur with normal activity
E. Peak expiratory fow (PEF) is greater than or equal to 80% of the predicted
value
A nurse is collecting data from a child who has acute appendicitis. Which of the
following findings should the nurse expect?
A. WBC 17,000/mm3
B. Left lower quadrant abdominal pain
C. Hyperactive bowel sounds
D. Bradycardia (tachycardia)
A nurse is caring for a toddler who has a cast applied 2 hr ago due to multiple
fractures of the right hand of the following findings should the nurse report
immediately to the charge nurse?
A. The fingers on the right hand have a capillary refill of 4 seconds
B. The fingertips of the right hand are swollen and bruised
C. The child is not attempting to move her right arm or fingers
D. The parents report the child will not keep the arm elevated on the pillow
A nurse is collecting data from a 3-year-old child who has acute diarrhea and
dehydration. Which of the following findings indicates that oral rehydration
therapy has been effective?
A. Heart rate 130/min
B. respiratory 24/min
C. urine specific gravity 1.015 (1.010-1.015) higher urine specific gravity is
dehydrationD. Capillary refill greater than 3 seconds
A nrse is caring for a school age child who has a new plaster cast on her right arm.
Which of the following actions should the nurse take?
A. Position the casted arm in a dependent position (worsen the edema.
Elevate it so there wont be edema, elevate it on a pillow )
B. Place a warm moist heat pack on the cast
C. Administer diphenhydramine to relieve itching
D. Move the casted arm with a firm grip
A nurse is caring for a child who is to receive percussion, vibration, and postural
drainage. Which of the following actions should the nurse take first?
A. Administer albuterol by nebulizer (open the airway, and loosen the
secretions it will be more effective to loosen it up)
B. Percuss the upper posterior chest
C. Perform vibration while the client exhales slowly through the nose
D. Instruct the client to cough
A nurse is caring for an infant who has spina bifida. Which of the following actions
should the nurse take?
A. Feed the infant through an BG tube
B. Place the infant in prone position
C. Cover the infants lesion with a dry cloth (cover infant with moist sterile
cloth)
D. Perform range of motion exercises to the infant’s hips
A nurse is planning care for a child who has epiglottitis. Which of the following
actions should the nurse plan to take?
A. Obtain a throat culture
B. prepare the child for a neck radiograph
C. initiate airborne precaution (droplet)
D. visualize the epiglottitis using a tongue depressor (it can stimulate spasm
and cause airway obstruction)
(manifestation of epiglottitis the patient has drooling)
A nurse is caring for a child who is experiencing a seizure. Which of the followingActions should the nurse take?
A. Elevate the childs legs on a pillow
B. Restrain the childs arm
C. Insert a padded tongue blade into the child’s mouth
D. Place the child in a side lying position(for aspiration)
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should
place the infant in which of the following positions after feeding?
A. Prone (fundamentals)
B. Upright (ATI)
C. Left side
D. Right side
A nurse is contributing to the plan of care for a 2month old infant who has just
undergone cleft palate repair. The nurse should contribute which of the following
interventions to the clients plan of care?
A. Feed the infant half strength formula for the first 48 hr. (NPO, start with
clear liquids not half strength formula)
B. Remove elbow restraints while the infant is sleeping (do not remove the
restraint unattended because when they sleep they can still touch the
operative site, u can remove it for a short period of time to just monitor)
C. Keep the infant in a side lying position
D. Administer pain medication PRN for the first 48 hr. (it should not be PRN it
should be scheduled)
A nurse is receiving hand off report for a toddler who has a fractured right femur
and is in 90 degree /90 degree traction. The nurse should expect to observe
which of the following?
A. Skin straps maintaining the affected leg in an extended positon
B. A skeletal pin in the distal end of the femur
C. A padded sling under the knee of the affected leg
D. The buttocks elevated slightly off of the bed
A nurse is caring for a child who is having a tonic clonic seizure and vomiting.
Which of th following action the nurse priority
A. Place a pillow under the childs headB. Move the child into a side lying position
C. Remove the childs eyeglasses
D. Time the seizure
A nurse is caring for a child who has tinea pedis. The childs parents ask the nurse
what this infection is commonly called. The nurse should respond with which of
the following common names
A. Shingles
B. Athletic foot
C. Fever blisters
D. Pinworms
A nurse is caring for a 6-month-old infant who is postoperative following a
myringotomy. Which of the following pain assessment scales should the nurse use
to determine the infants pain level?
A. FLACC
B. Oucher
C. FACES
D. Visual analog scale
A nurse is collecting data from a child who has spina bifida occulta. Which of the
following findings should the nurse expect?
A. Hip dislocation
B. Flaccid paralysis of lower extremities
C. Hydrocephalus
D. Dimple in sacral area
A nurse is caring for a 2 week old infant who’s mother requests additional
information about sudden infant death syndrome (SIDS). Which of the following
responses should the nurse make?
A. You should place your baby on her back when sleeping to decrease the risk
of SIDS
B. SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines
C. SIDS rates have been rising over the last 1- years
D. Sleep apnea is the main cause of SIDSA nurse is caring for a newly admitted adolescents who has anorexia nervosa.
Which of the findings should the nurse expect
A. Diarrhea
B. Hypertension
C. Tachycardia
D. Lanugo
A nurse is collecting data from a child who has (beta) B-thalassemia. Which of the
following findings should the nurse expect?
A. Hyperactivity (hypoactivity)
B. Increased appetite (decreased appetite)
C. Fever
D. Flushed of skin (pale skin)
A nurse in a clinic is preparing to administer pre-k-kindergarten vaccines to a 5
year old child whose medical record indicates that his immunization are up to date
which of the following vaccines should the nurse plan to adminiser
A. Mealsles, mumps, rubella (MMR)
B. Haemophilus influenza type B HIB
C. Pneumococcal conjugate vaccine (PCV)
D. Heptatits B (HBV)
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which
of the following actoons should the nurse take?
A. Ask another nurse to assist with holding the toddler in a prone position
B. Restrain the toddler for 1 hr after the procedure
C. Place the toddler in a side lying knee chest position
D. Swaddle the toddler in a warm blanket
A nurse is planning to speak to a group of adolescents about toxic shock syndrome
(TSS) the nurse include that TSS is a commonly assoiciated with which of the
folloqing?
A. High absorbency tampons
B. Mosquito bites
C. International travelD. Multiple sexual partners
A nurse is talking with a 13 year old female clients who is having her annual health
screening visit. Which of the following comments by the client should concern the
nurse?
A My parents treat me like a baby sometimes
B I start taking ibuprofen a few days before my period starts
C None of the kids at my school like me and I don’t like them either
D Theres a pimple on my face and iw orry that everyone will notice it
A nurse is caring for a 6 month old child. The childs provider has ordered a
diphtheria, tetanus, and pertussis (DTAP) vaccine to be administered. Which of the
following should cause the nurse to question the administration of this vaccine?
A. Febrile otitis media
B. Evidence of sensitivity to egg atigens
C. Temp of 40.5 C (104.9F) after last DTAP
D. New onset of seizurs disorder in the childs sibling
A nurse is caring for an adolescent. The nurse should expect that the adolescent is
working on which of the following developmental tasks?
A. Building a sense of trust (infant)trust vs mistrust
B. Learning to use creative energies (school aged)
C. Learning to perform tasks independently (toddler)autonomy vs shame and
doubt
D. Defining a sense of self (Adolescence)
A nurse is selecting a toy for a 7 month old infant. Which of the following toys
should the nurse choose?
A. A set of blocks to build a block tower
B. A colorful crib mobile that plays music
C. A soft toy that squeaks or crackles when squeezed
D. A wooden farm animal puzzle with large pieces
A nurse is reinforcing teaching with the parents of an 8 month old infant who will
be admitted for surgery. Which of the following instructions should the nurse
include in the teaching?A. You will need to go home when it is not visiting hours
B. You should bring the infants favorite blanket to the hospital
C. You should begin to manipulate the infants bedtime based on the hospital
visitng hours
D. You should read the childs a story about hospitalization
A nurse is collecting data regarding the pain level of a 3 year old child on the
second postoperative day following an appendectomy. Which of the following
actions should the nurse take?
A. Use a numeric scale to assess the childs pain level
B. Use the FACES scale to assess the childs pain level
C. Use a color tool to assess the childs pain level
D. Use the visual analog scale to assess the childs pain level
A nurse in a pediatric clinic is collecting data from a preschool age child who has
suspected impetigo contagiosa. Which of the following manifestations should the
nurse expect to find with this skin infection?
A. Scaly patches that have clear centers (ring worm)
B. Red macule with honey colored crusts
C. Firm brown papules with a roughened, finely papillomatous texture
D. Reddened areas with white exudate
A nurse is reinforcing teaching with an adolescent regarding administration of the
Gardasil vaccine. The vaccine provides Immunity against which of the following
sexually transmitted infections?
A. Human papillomavirus (HPS)
B. Herpes simplex virus ( HSV-2)
C. Chlamydia trachomatis
D. Gonorrhea
A nurse is collecting data from a 7 month old infant which of the following findings
should indicate to the nurse a need for further evaluation?
A. Usees a unidextrous grasp
B. Has a fear of strangers
C. Sits leaning forward on both hands
D. Babbles one syllable soundsA nurse is collecting data from a child who is postoperative following a
tonsillectomy. Which of the following is a clinical manifestation of hemorrhage?
A. Increased pain
B. Poor fluid intake
C. Drooling
D. Continuous swallowing
A nurse is assisting with the admission of a child who has pertussis. Which of the
following actions should the nurse take?
A. Initiate a protective environment
B. Initiate airborne precautuons
C. Initiate droplet precautions
D. Initiate contact precautions
A nurse is caring for a child who has erythema infectiousm. Which of the following
findings should the nurse expect?
A. Facial erythema
B. Koplik spots (measles)
C. Parotitis (mumps)
D. Pruritus (itchiness. Chicken pox)
A nurse is collecting data from an infant who has developmental dysplasia of the
hip (DDH) which of the following findings should the nurse expect?
A. Absent plantar reflexes
B. Lengthened thigh on the affected side
C. Inwardly turned foot on the affected side
D. Asymmetric thigh folds
A nurse is caring for a child who has nosebleed. Which of the following actions
should the nurse take?
A. Place the child in a sitting position and tilt her head back
B. Apply ice at the opening of the nares for 5 min and then recheck for
bleeding
C. Place the child In a supine position with a pillow under her head
D. Have the child sit with her head tilted forward and hold pressure on her
nose for 10 mins (use ur fingers pinching the nose)A nurse is collecting data from a 1 year old child who has Wilms tumor. Which of
the following findings should the nurse expect?
A. Jaundice
B. Swollen joints
C. Abdominal mass
D. Diarrhea
A nurse is caring for a school age child who has acute glomerulonephritis. The
child has peripheral edema and is producing 35mL of urine per hour. Which of the
following diets should the nurse anticipate the provider will prescribe?
A. Low sodium, fluid restricted
B. Regular diet no added salt
C. Low carbohydrate, low protein diet
D. Low protein. Low potassium diet
A nurse is preparing to administer vaccines to a 4 month old infant. Which of the
following vaccines should the nurse to administer?
A. Rotavirus
B. Influenza
C. MMR (measles, mumps, rubella)
D. Varicella (VAR)
A nurse is collecting data from an infant at well-child visit. The nurse should
expect the infant to double his birth weight by which of the following ages?
3 months
6 months
9 months
12 months
NURSE IS CARING for a child who reports being physically abused by a family
member. Which of the following statements should the nurse make?
A. I promise I wont tell anyone about this
B. Lets discuss what you have told me with your family members
C. Your family is bad for doing this to you,D. IT is not your fault that this happened
A nurse is caring for a child who has acute diarrhea and reports that he is thirsty.
Which of the following fluids should the nurse give the child?
Birtth
Cherry Gelain
Apple juice
Pedialyte
A nurse is preparing to administer immunizations to a child who has an allergy to
eggs. The nurse should know that an allergy to eggs is a contraindication for which
of the following immunizations ?
A Influenza (TIV)
B Inactivated poliovirus (IPV)
C Haemophilus Influenza tybe B (HiB)
D Hepatitis B (Hep B)
A NURSE on e medical-surgical unit is caring for a group of children. Which of the
following findings should alert the nurse tha one of the children is a potential
victim of abuse?
A. A toddler who has multiple Bruises on the sins of both legs and his parents
report that he is clumsy.
B. A preschooler who has a BMI indicating Obesitiy.
C. A school age child who cries when the nurse is giving him an injection
D. An adolescent who asks to stay in the hospital because he likes the room
A nurse is prepeating to administer IM injection to a preschool-age child. Which of
the following actions should the nurse take?
A. Ask the parents to hold the child
B. Allow the child to hold a favorite toy.
C. Administer the medication in the child’s room
D. Tell the child the medicine will make him feel better.A nurse is contributing to the plan of care of an unconscious adolescent who
ingested a non corrosive substance that has no recommended antitode. The nurse
should recommend to perform gastric lavage with which of the following
substances?
A. 0.9% sodium chloride
B. Syrup of Ipecac
C. Osmotic Diarrheal agents
D. Activated Charcoal (absorbs toxins in the stomach , Mixed with Saline for
aspiration via NG tube )
A nurse is reinforcing teaching about preventing disease tansmission with the
parents of a child who has a streptococcal infection. Which of the following
instructions should the nurse include?
A. Ill continue to encourage him to drink lots of fluids.”
B. Ill take his temp. Q 4 hours”
C. Ill give him acetaminophen for the pain
D. Ill discard his toothbrush and buy another “
A nurse on a pedicatric unit is caring for a client who has brain tumor. To help
ensure the lcients safety, which of the following actions should the nurse take?
A. Do not allow the child to ambulate in his room alone.
B. Limit contact with other pediatric clients.
C. Initiate Seizure precautions for the child
D. Have the child use a wheelchair for all out-of-bed activities
A nurse is caring for a child who is having seizure. Which of the following actions
should the nurse take? ( select all that apply )
A. Elbow
B. Mummy
C. Wrist
D. JacketA nurse is caring for a child who is having seizure. Which of the following actions
should the nurse take ( SELECT ALL THAT APPLY)
A loosen restrictive clothing
B place a tongue depressor in the child’s mouth
C clear the area of hard objects
D Place the child in prone positions
E Restrain the child
83?...A nurse enters a school age child’s room to administer morning medications
and finds the client sitting in a chair having a seizure. After lowering the client to
the
floor
Lateral position
A nurse is assiting with the care of a child with spina bifida. Which of the folloing
precations should nurse take while caring for this child?
Precautions for Spina Bifida -- Latex Precautions
A nurse is assisting with the admission of an infant who has resp. Syncytial Virus
(RSV) which of the following rooms should the nurse assign the infant?
A. A semi-private room with an infant who has a croup
B. A semi-private room with a toddler who has pneumonia
C. A private room with contact/droplet precautions
D. A private room with protective isolation
A nurse is reinforcing teaching with new parents about risk factors for the sudden
infant death syndrome (SIDS). Which of the following statements by a parent
indicates an understanding of the teaching?
A. “Our baby will sleep in my bed because I am breastfeeding.”B. I do not plan to offer my baby a pacifier during naps or at bedtime
C. My baby will be placed on her back when sleeping
D. We will place an antique quilt in out baby’s crib.”
A nurse is caring for an adolescent client who is receiving carbamazepine for
partial seizure disorder. Which of the following statements by the adolescent
parent is the priority for the nurse to addresss?”
A. He only sleeps 5 hours each night
B. HE takes his medication between meals with water
C. He seems to be getting a lot more bumps and bruises lately
D. HE has not been eating as much lately”
A nurse is caring for a toddler who has laryngotrachobronchitis ( LTB ) For which
of the following findings should the nurse monitor to detect airway ob struction?
A. Decreased Stridor (increase airway becomes more obstructive)
B. Decreased Restlessness ( increase )
C. Increased Heart rate ( in order to deliver more blood pump more oxygen
)
D. Decreased Temperature ( Increased Temperature )
A nurse is reinforcing teaching with the mother of a 2-month old infant whose
provider applied a Paylik Harness 1 week earlier for the treatment of
developmental hip dysplasia. Which of the following statements. Which of the
following statements by the mother indicates an understanding of the teaching?
A. I will adjust the harness straps every day.”
B. I will place the diaper over the harness.” ( Under the Harness )
C. I will check my baby’s skin three times each day.
D. I will gently massage lotion on his skin around the harness clasps.” (Build
up in skin and cause irritation )
A nurse reinforcing teaching with the parents of a school-age child who has cystic
fibrosis. Which of the following statements should the nurse make?A administer a bronchodilator to the child after chest percussion therapy .” (
B. a pigeon- shaped chase might become evident as the disease progressing. “
C. Bradycardia is an early indicator of pneumothorax.”
D. Engage the child in daily aerobic exercise. “(help promote erection of the
mucus. Endorphine will Rise. YEEEE)
A nurse is a collecting data from an infant which of the following is a clinical
manifestation of pyloric stenosis?”
A. Absent Bowel sounds (appendeictis and hirchsprung disease)
B. Increased Sodium Level (decrease because of vomiting)
C. Projectile Vomiting after feedings
D. Golf- ball size over the left quadrant (olive shaped mass) (On the right of
Umbilicus )
A nurse is planning meals for a 2-year child who has a fractured jaw and is having
difficult swallowing. The surgeon has prescribed a pureed diet. Which of the
following food selections should the nurse make?
A. scrambled egg (Pureed)
B. Cottage Cheese (mechanical diet)
C. Dried fruit
D. Peas
A nurse reincofrcing teaching the parents of a pre schooler who has a atopic
dermatitis. Which of the following information should the nurse include?
You’ll need to take the entire prescription of antibiotics even if your
symptoms improved.
The doctors may recommend anti-histamines to help control symptoms.
You can relieve your child’s iscomfort by applying warm compression of the
lesion
The doctor will remove the lesions with the liquid nitrogenA nurse is contributing to the plan of care of a 14-month old toddler who is 24
hour post-OP following a cleft palate repair. Which of the following interventions
should the nurse include in the plan?
A. Provide soft foods for the toddler.
B. Suction the toddler nose and mouth every hour
C. Maintain elbow restraints on the toddler
D. Give the toddler a hard – tipped sippy cup to drink liquids.
A nurse is collecting data from an infant who has Gastroesophageal reflux (GERD) .
Which of the following findings should the nurse expect? ( select all that apply)
A. Vomiting
B. Weight Loss
C. Rigid Abdomen ( for Appendecitis )
D. Wheezing
E. Pallor
A nurse is caring for a toddlet who has intusussepction. Which of the following
manifestations should the nurse expect?
A. Drooping
B. Increased Appetite
C. Jaundice
D. Mucus in Stools
A nurse is caring for a 4-year old child who refuses to take his medication
because of the bad taste. Which of the following strategies should the nurse use
to medication
A. Offer the child an ice pop prior to administering the medication ( numb the
tongue …Nerves )
B. Tell the child the medicine tastes like candy
C. Hide the medication in apple slices.
D. Inform the child that if he does not take the medication he will need a shot.A nurse is reviewing the medical record of an adolescent and notes a calcium
level of 11.5 mEq/L Which of the following findings should the nurse expect?
( 9- 10.5 = Normal Calcium level )
A. Diarrhea
B. Muscle Hypotonicity
C. Tachycardia ( HypoCalcemia )
D. Positive Chvostek’s sign ( HypoCalcemia) (Face twitching after a tap )
tappity tap
A nurse is planning care for a 4-year old child who has been admitted to the
hospital. Which of the following toys. Should the nurse plan to provide the child?
A. Modeling Clay
B. Brightly Colored mobile ( INFANTS )
C. 100- piece jigsaw puzzle ( TOO MUCH APPARENTLY )
D. Checkerboard and Checkers ( SCHOOL AGE 6-12 Y/O )
A nurse is reincofrcing teaching about elimination with an adolescent who is
paralyzed from the waist down following a spinal cord injury. Which of the
following statements by the adolescent indicates a need for further teaching ?
A. “ I need to catheterize myself twice a day. “ ( Catheterize every 4-6 Hours
)
B. I carry a water bottle with me because I drink a lot of water.”
C. I used a suppository every night to have a bowel movements .”
D. I do my wheelchair exercises sitting in my chair
A parent asks a nurse about toys to provide for a 10-month old infant. Which of
the following toys should suggest?
A. Push- Pull Toy (B. Crib Gym
C. Large-Piece puzzles
D. Coloring book with crayons [Show Less]