Which client requires immediate intervention by the RN?
• A child with cystic fibrosis who is constipated.
• A toddler with chicken pox who is
... [Show More] scratching,
• A child with acute renal failure and hyperkalemia.
• An adolescent with a migraine and photophobia.
A 7 year old male is referred to the school clinic because he fainted on the playground. His
height is 3 feet, 7 inches (107.5 cm), he weighs 55 pounds (25 kilograms), and his body mass
index (BMI) is 20.9. Which assessment finding is most important for the RN to address?
• He consumed2 bottles of water in 30 minutes prior to fainting.
• Since age 3 he has experienced exercise induced asthma.
• Reports drinking 3-4 high calorie, carbonated beverages daily.
• The child’s father has a history of fainting when exercising.
The RN of a 6 year old girl is concerned about her child’s obesity. The child’s weight plots at the
75th percentile, and height at the 25th percentile. The child’s body mass index (BMI) is at the
85th percentile for age and gender. Which interventions should the RN implement? (Select All
That Apply)
• Explain that the child is likely to grow into her weight.
• Determine the child’s usual physical activity pattern.
• Obtain the child’s 3- day diet history based on the mothers input.
• Inquire as to whether or not the school has a physical education
program.
• Tell the mother that girls hit their growth spurt before boys so eating more
is expected.
(B, C, and D) are correct. The child’s growth parameters, particularly her BMI, indicate that she
is overweight. (B and D) assess for the child’s level of activity, which should be evaluated and
increased if possible. (C) Provides information about the quantity and quality of the child’s
dietary intake, which is information that is needed to create an individualized diet teaching plan.
(A) Does not consider the serious health and psychological consequences associated with
childhood obesity. Girls do not hit their growth spurt before boys in preadolescence, but this
child is only 6 years of age and the child’s obesity should not be negated because of this growth
and development expectation. (e)
A toddler with hemophilia is being discharged from the hospital. Which teaching should the RN
include in the discharge instructions to the mother?
• Apply padding on the sharp corners of the furniture.
• Prevent the client from running inside the house.
• Give an 81 mg tablet of aspirin for pain relief.
• Use a soft bristle toothbrush from frequent cleaning.
The RN is examining an infant for possible cryptorchidism. Which examine technique should be
used?
• Place the infant in a side lying position to facilitate the exam.
• Hold the penis and extract the foreskin gently.
• Cleanse the penis with an antiseptic-soaked pad.
• Place the infant in a warm room and use a calm approach.
An infant who has been diagnosed with a tracheoesophageal fistula (TEF). What nursing
intervention is indicated for this infant prior to surgical repair?
• Provide frequent sips of liquid.
• Give isotonic enemas as prescribed.
• Maintain nothing by mouth status.
• Prepare the infant for a barium enema.
An adolescent with non- Hodgkin’s lymphoma (NHL) is complaining of a sore mouth two days
after beginning chemotherapy. What activity should the RN implement?
• Encourage large meals during steroid and chemotherapy.
• Provide lemon glycerin swabs and dilute peroxide oral rinses.
• Recommend fluids using citrus juices and drinking with a straw.
• Frequent use of saline oral rinses and a soft sponge toothbrush.
A child with acute laryngotracheobronchitis (croup) received epinephrine 2 hours ago in the
emergency room, and now is being prepared for discharge to go home. The RN should instruct
the parents to take which action if the child’s uncontrolled coughing reoccurs?
• Call for emergency transportation to the hospital.
• Increase the fluid intake to liquefy the secretions.
• Administer a dose of the prescribed cough medicine.
• Sit with the child in the bathroom with hot steam.
Moist, warm air (D) promotes bronchodilation, which helps relieve spasms that cause the
coughing. If the symptoms continue or worsen, the child may need to be transported to the
hospital (A). Fluids will thin the secretions (B) and cough medicine (C) may decrease cough, but
neither of these interventions decrease swelling or dilate the airway to improve breathing.
The RN is performing a routine examination of a 6-month old infant at the community health
clinic. Records indicate that the child weighed 3 kg at birth. The clinic uses lbs to describe
weight. When assessing this child, approximately what weight, in lbs, should the RN
consider to be within normal range for this child?
• 15 to 18 lbs.
• 12 to 15 lbs.
• 9 to 11.5 lbs.
• 6 to 7.5 lbs.
Birth weight should at least be double at this time.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type
1 Diabetes Mellitus, the RN should instruct the client to eat a source of sugar if which symptom
occurs?
• Excessive thirst.
• Racing pulse.
• Profuse perspiration.
• Seeing spots.
Tachycardia is one of the symptoms of hypoglycemia.
A breast feeding mother returns to work when her infant is 5 months old. She is having difficulty
pumping enough milk to mete her infant’s dietary requirements. Which suggestion should the
RN provide to this mother?
• Mix infants formula with breast milk.
• Supplement with an iron-rich formula.
• Introduce baby food for one meal daily.
• Offer a follow-up transitional formula.
The RN is evaluating the effects of thyroid therapy used to treat a 5 month old with
hypothyroidism. Which behavior indicates that the treatment has been effective?
• Keeps fists clenched, opens hands when grasping an object.
• Has strong Moro and tonic neck reflexes.
• Can lift head, but not chest when lying on abdomen.
• Laughs readily, turns from back to side.
The RN is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both
lung fields. Which additional finding should the RN expect to obtain?
• Vigorous feeding and sanitation.
• Hemiplegia.
• Fever.
• Hypotension and tachycardia.
A child with possible Duchenne muscular dystrophy (MD) undergoes an electro-myelogram
(EMG). Following the procedure, the child’s parents tell the RN that the child is complaining of
sore muscles. How should the RN respond?
• Explain that muscle aches and pain are commonly experienced by children
with this form of muscular dystrophy.
• Advise the parents that children with chronic diseases may seek attention
by reporting pain or other unpleasant symptoms.
• Encourage the parents to monitors the child’s body temperature for the
next 24 hours and report a rise above 101 degree F.
• Offer reassurance that muscle soreness following this procedure is
temporary and does not indicate a problem.
During an EMG, small needles are placed in the muscles to record contractions. This can cause
temporary muscle aches following the procedure (D). Muscle weakness and hypertrophy,
followed by atrophy are associated with MD rather than pain (A). Muscle soreness is an expected
finding following an EMG and does not indicate attention-seeking behavior (C). It is not
necessary to monitor body temperature (C) following EMG.
The heart rate of a 3 year old with a congenital heart defect has steadily decreased over the last
few hours, and is now at 76 beats/minutes; the previous reading 4 hours ago was 110 beats/
minutes. Which additional clinical finding should be reported immediately to the healthcare
provider?
• Respiratory rate of 25 bpm.
• Urine output of 20 mL/hr.
• Oxygen saturation of 94%.
• Blood pressure of 70/40
The HCP prescribes epinephrine 0.01 mg/kg IM for a child with asthma who weighs 55 lbs. The
available medication is labeled, 1 mg/ml. based on the child’s weight, how many mL should the
RN administer?
After receiving a single fluid bolus of 20 mL/kg of NS, a child’s heart rate is 140 bpm, blood
pressure 70/50, and capillary refill is 6 seconds. The child is anxious and crying. Which
intervention should the RN implement first?
• Repeat the NS bolus as prescribed.
• Allow the child to assist with caregiving.
• Recommend age appropriate activities.
• Encourage the caregiver to remain at bedside.
The RN should instruct the parents of an 8 year old child who has sickle cell anemia to be alert
for which complaint from the child?
• “I’m shorter than everyone else.”
• “I’m really hot and thirsty.”
• “I don’t want to eat any vegetables.”
• “I have to urinate every few hours.”
Parents needs to be alert to situations where dehydration may be a possibility. Symptoms such as
decreased urinary output and increased thirst indicate dehydration, which precipitate a sickle cell
crisis (B). (A) Is sometimes expected with children with sickle cell anemia, especially if the child
experiences many crisis. Many children do not like vegetables (C). Needing to urinate every few
hours is not a warning sign for a possible sickle cell crisis (D); in fact, it may indicate adequate
hydration.
The RN is assessing an 8 month old who has a cough, axillary temperature of 100, and
rhinorrhea. What information is most important for the RN to obtain from this child’s mother?
• Living conditions.
• Labor and delivery history of the infant.
• Immunization status of the infant.
• Alcohol and drug intake of the mother.
A milder form of pertussis occurs in children who are partially immunized, so immunization
status (C) Is important in planning care. In the catarrhal stage, the clinical manifestations
resemble upper respiratory infection. Information on (A) is not an immediate concern, but
discharge planning should include discussion of family health problems or environmental
conditions that could affect the infant. (B and D) are more important in planning the care of a
newborn infant, but are not significant for a child 8 months of age.
During a routine clinic visit, the RN determines the 5 year old girl’s systolic blood pressure is
greater than the 90th percentile. What action should the RN implement next?
• Take the blood pressure two more times during the visit and determine the
average of the three readings.
• Measure the child’s blood pressure three times during the visit and
determine the highest of the readings.
• Conduct a head to toe assessment and omit repeated blood pressures
during the examination.
• Refer the child to the HCP and schedule evaluation of blood pressure in
two weeks.
A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. What
action should the RN implement first?
• Initiate an IV site and begin infusing normal saline.
• Type and cross for possible transfusion.
• Monitor the child’s vital signs frequently.
• Apply ice pack and compression dressing to knee.
Rest, Ice, Compression (D), and elevation are immediate treatments that should be implemented
to reduce swelling and bleeding in the joint. Blood loss within the knee is not immediately life
threatening, so further assessment is needed to determine if an infusion of normal saline (A), or a
blood transfusion (B) are indicated. Baseline vitals should be obtained, but frequent vital signs
(C) are not immediately indicated.
What snack is best to provide a 6 year old on prescribed bedrest while receiving treatment for
osteomyelitis?
• Milkshakes.
• Soup broth.
• Apple sauce.
• Popsicle.
A young child with osteomyelitis needs high calorie/ high protein snacks to maintain adequate
nutrition and promote healing, and a milkshake (A) is the best choice to meet this dietary
objective. (B, C, and D) are low in protein and provide minimal calories.
An 8 year old is admitted to the emergency Department because of lower right quadrant pain,
nausea, and vomiting. Which assessment of the abdomen should the RN conduct after all other
assessments are complete?
• Percussion.
• Palpation.
• Inspection.
• Auscultation.
A one month old male infant is brought to the clinic by his mother who states that her son has
been vomiting forcefully after each meal for the last three days. The infant is afebrile,
dehydrated, and pyloric stenosis is suspected. What other findings should the RN identify that
are consistent with pyloric stenosis?
• Perianal diaper rash from persistent diarrhea.
• Rooting, hunger, and irritability.
• Bile-stained emesis.
• An olive-shaped mass in the abdominal area.
A RN is evaluating a young child with atopic dermatitis. Which question should the RN ask the
parent while obtaining the child’s history?
• “Does the child have any nausea or vomiting?”
• “Has the child displayed any symptoms of asthma or hay fever?”
• “Can any particular stress be associated with onset of rash?”
• “What time of the day does the rash appear on the body?”
Atopic dermatitis is known to be associated with asthma and hay fever (B). There is no
significant association between atopic dermatitis and gastrointestinal symptoms (A). There is no
evidence that stress can cause atopic dermatitis, although stress is associated with the disease
during exacerbations (C). The rash persists over a period of time, and is not associated with
diurnal pattern (D).
A 3 month old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health RN notes that the child developed episodes of
sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for
the RN to take?
• Auscultate the lungs for respiratory pneumonia.
• Draw blood to analyze for streptococcal infection.
• Change to latex free gloves when handling infant.
• Apply zinc oxide to perineum with each diaper change.
A rash with urticaria, sneezing, and watery eyes are classic symptoms of an allergic reaction.
Latex allergy is a serious threat created by the repeated catheterizations using pre-packaged
gloves, so the RN should use latex free gloves (C). The skin rash and urticaria are not typical of
(A or B). (D) is ineffective in treating in allergic reaction.
A 17 year old male student with cystic fi...............................................................................................CONTINUED [Show Less]