• The parent of a 12-year-old male child with a left below-the-knee cast calls the pedi- atric clinic nurse and tells the nurse, "My son's foot is cold
... [Show More] and he told me it feels like his foot is asleep." Which action should the nurse implement first?
3. Instruct the parent to elevate the left leg on two pillows.
Correct - 3. The nurse should first take care of the client's body by having the parent elevate the left leg.
• Which child requires the nurse to notify the healthcare provider?
1. The 1-year-old child with iron deficiency anemia who has dark-colored stool.
2. The 3-year-old child with phenylketonuria (PKU) whose parent does not feed the child any meat or milk products.
3. The 5-year-old child with rheumatic heart fever who is having difficulty breathing.
4. The 7-year-old child diagnosed with acute glomerulonephritis who has dark "tea"-colored urine.
Rationale
Correct - 3-A complication of rheumatic heart disease is valvular disorders that may be mani- fested by respiratory problems; therefore, the nurse should notify the child's health- care provider.
• The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first?
1. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo- cele who has bulging fontanels.
Correct - 1-Bulging fontanels is a sign of increased intracranial pressure, which is a compli- cation of neurological surgery; therefore, this child should be assessed first.
• The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse?
4. The staff nurse places the child in semi-Fowler's position to eat lunch. Rationale
Correct - 4-The child should be positioned upright to prevent aspiration during meals; there- fore, this action would require the charge nurse to intervene.
• The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation?
4. The nurse checks to make sure the UAP's delegated tasks have been completed. Rationale
Correct - 4. The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately.
• The nurse on a pediatric unit has received the a.m. shift report and tells the unli- censed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?
1. Determine what the UAP did not understand about the instruction. Rationale
Correct - 1.Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first.
I. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries that must be assessed and treated promptly.
II. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?
Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication.
III. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel won't spin. Which action should the nurse implement first? Correct -1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked.
IV. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first.
V. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?
Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must be administered first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, this medication does not have to be adminis- tered first.
VI. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure?
D. Reactions to previous hospitalizations Rationale
Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure
VII. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination?
) Auscultate the lungs and heart while the infant is still sleeping. Rationale
When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination. [Show Less]