The nurse is caring for a 3-year old child who is 2 hours post-op from a cardiac
catheterization via the right femoral artery. Which assessment finding
... [Show More] is an
indication of arterial obstruction? - Right foot is cool to the touch and appears pale
and blanched.
Following a motor vehicle collision, a 3-year old girl has a spica cast applied.
Which toy is best for the nurse for this 3 year old child? - Set of cloth and hand
puppets.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which
action should the nurse implement first? - Place the infant in a knee-chest position.
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul
respirations. The nurse determines that the increased respiratory rate is a
compensatory mechanism for which acid base alteration? - Metabolic acidosis
7 years old is admitted to the hospital with persistent vomiting, and a nasogastric
tube attached too low intermittent suction is applied. Which finding is most
important for the nurse to report to the healthcare provider? - Serum potassium of
3.0 mg/dL.
The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac
disease). Choosing which food indicates that the teaching has been effective?
A. Creamed corn.
B. Pancakes.
C. Rye crackers.
D. Cooked oatmeal. - A. Creamed corn.
During a well-baby check, the nurse hides a block under the baby's blanket, and the
baby looks for the block. Which normal growth and development milestone is the
baby developing? - Object permanence
The nurse is measuring the frontal occipital circumference (FOC) of a 3-months
old infant, and notes that the FOC has increased 5 inches since birth and the child's
head appears large in relation to body size. Which action is most important for the
nurse to take next? - Palpate the anterior fontanel for tension and bulging.The nurse is preparing a 10 year old with a lacerated forehead for suturing. Both
parents and 12 year old sibling are at the child's bedside. Which instruction best
supports family? - Please decide who will stay when the healthcare provider begins
suturing.
The nurse is planning for a 5-month old with gastroesophageal reflux disease
whose weight has decreased by 3 ounces since the last clinic visit one month ago.
To increase caloric intake and decrease vomiting, what instructions should the
nurse provide this mother? - Thicken formula with cereal for each feeding.
While teaching a parenting class to new parents the nurse describes the needs of
infants and toddlers regarding discipline and limit setting. What is the most
important reason for implementing such parenting behaviors? - They provide the
child with a sense of security.
The parents of a newborn infant with hypospadia are concerned about when the
surgical correction should occur. What information should the nurse provide? -
Repairs typically should be done before the child is potty trained.
Which drink choice on a hot day indicates to the nurse that a teenager with sickle
cell anemia understands dietary consideration related to the disease? - Lemonade
The nurse is assessing an infant with diarrhea and lethargy. Which finding should
the nurse identify that is consistent with early dehydration? - Tachycardia
While auscultating the lung sounds of a 5 year old Chinese boy who recently
completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round,
bruise-like blemishes on his chest. What action is best for the nurse to take? -
Inquire about the use of alternative methods of treatment.
A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy
via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing
the IV site, the nurse determines that there are no signs of infection at the site.
Which intervention is the most important for the nurse to implement? - Obtain
specimen for blood cultures.
A child who weights 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in
equally divided doses every 4 hours. How many mg should the nurse administer to
the child for each dose? - 1875 mgThe nurse is caring for an infant scheduled for reduction of intussusceptions. The
day before the scheduled procedure the infant passes a soft-formed brown stool.
Which intervention should the nurse implement? - Notify the healthcare provider
of the passage of brown stool.
The mother of a 4-month old asks the nurse for advice in preventing diaper rash.
What suggestion should the nurse provide? - Use a barrier cream, such as zinc
oxide, which does not have to be completely removed with each diaper change
Which statement by a school aged client going to summer camp indicates the best
understanding of the mode of transmission of Lyme disease? - I have to wear long
sleeves and pants when we're hiking around the pond
The nurse is evaluating the effects of thyroid therapy used to treat a 5 months old
with hypothyroidism. Which behavior indicates that the treatment has been
effective? - Laughs readily, turns from back to side.
The HR for a 3 year old with a congenital heart defect has steadily decreased over
the last few hours, now it's 76 bpm, the previous reading 4 hours ago was 110 bpm.
Which additional finding should be reported immediately to a healthcare provider?
- BP 70/40
2 year old is admitted to the hospital with possible encephalitis, and a lumbar
puncture is scheduled. Which information should the nurse provide this child
concerning the procedure? - Describe the side-lying, knees to chest position that
must be assumed during the procedure.
The parents of a 3 y/o boy who has Duchenne muscular dystrophy (DMD) ask
"how can our son have this disease? We are wondering if we should have any more
children" What information should the nurse provide these parents? - This is an
inherited X-linked recessive disorder, which primarily affects male children in the
family
A 3 year old with HIV infection is staying with a foster family who is caring for 3
other foster children in their home. When one of the children acquires pertussis, the
foster mother calls the clinic and asks the nurse what she should do. Which action
should the nurse take first? - Review the immunization documentation of the child
who has HIVA 16 y/o female student with a history of asthma controlled with both an oral
antihistamine and an albuterol (Provenfil) metered-dose inhaler (MDI) comes to
the school nurse. The student complains that she cannot sleep at night, feels shaky
and her heart feels like it is "beating a mile per minute" Which information is most
important for the nurse to obtain? - How often the MDI is used daily
The nurse is assessing a child for neurological soft signs, which finding is most
likely demonstrated in the child's behavior? - Poor coordination and sense of
position
The nurse is assessing an infant with pyloric stenosis. Which pathophysiological
mechanism is the most likely consequence of this infant's clinical picture? -
Metabolic alkalosis
A 4 month-old girl is brought to the clinic by her mother because she has had a
cold for 2 o 3 days and woke up this morning with a hacking cough and difficulty
breathing. Which additional assessment finding should alert the nurse that the child
is in acute respiratory distress? - Flaring of the nares
A two year old boy begins to cry when the mother starts to leave. What is the
nurse's best response in this situation? - Let me read this book to you
A two year old child with a heart failure (HF) is admitted for replacement of a graft
for coarctation of the aorta. Prior to administering the next dose of digoxin
(Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should
the nurse implement? - Administer the scheduled dose
A child with leukemia is admitted for Chemotherapy and the nursing diagnosis
"altered nutrition, less those body requirements related to anorexia, nausea and
vomiting" is identified. Which intervention the nurse included in this child plan of
care? - Allow the child to eat any food desired and tolerated
A 6 year old who has asthma is demonstrating a prolonged expiratory phase and
wheezing and has a35% of personal best peak expiratory flow rate (PEFR) based
on these finding, actions should the nurse take first? - Administer a prescribed
bronchodilator [Show Less]