1.The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure. The nurse should assess the infant for which early
... [Show More] sign of HF?
a.Pallor
b.Cough
c.Tachycardia
d.Slow and shallow breathing - correct answer c. Tachycardia
2.The nurse reviews the laboratory results for a child with suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?
a.Immunoglobulin
b.Red blood cell count
c.White blood cell count
d.Anti-streptolysin O titer - correct answer d. Anti-streptolysin O titer
3. On assessment of a child admitted with a diagnosis of acute stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
a.Cracked lips
b.Normal appearance
c.Conjunctival hyperemia
d.Desquamation of the skin - correct answer c. Conjunctival hyperemia
4.The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?
a."I will not mix the medication with food."
b."I will take my child's pulse before administering the medication."
c."If more than 1 dose is missed, I will call the health care provider."
d."If my child vomits after medication administration, I will repeat the dose." - correct answer d. "If my child vomits after medication administration, I will repeat the dose."
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
a.Weighing the diapers
b.Inserting a urinary catheter
c.Comparing intake with output
d.Measuring the amount of water added to formula - correct answer a. Weighing the diapers
6. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
a. Pallor
b. Hyperactivity
c. Exercise intolerance
d. Gastrointestinal disturbances - correct answer c. Exercise intolerance
7. A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?
a. "Has the child complained of back pain?"
b. "Has the child complained of headaches?"
c. "Has the child had any nausea or vomiting?"
d. "Did the child have a sore throat or fever within the last two months?" - correct answer d. "Did the child have a sore throat or fever within the last two months?"
8. A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?
a. During sleep
b. When changing the infant's diapers
c. When the mother is holding the infant
d. When drawing blood for electrolyte level testing - correct answer d. When drawing blood for electrolyte level testing
9.Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder?
a. Aortic stenosis
b. Arterial septal defect
c. Patent ductus arteriosus
d. Ventricular septal defect - correct answer c. Patent ductus arteriosus
10. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?
a. Warm, dry skin
b. Decreased wheezing
c. Pulse rate of 90 beats/minute
d. Respirations of 18 breaths/minute - correct answer b. Decreased wheezing
11. The mother of an 8-year-old child being treated for right lower love pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the ride side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
a. Increase the dose of ibuprofen
b. Increase the frequency of ibuprofen
c. Encourage the child to lie on the left side
d. Encourage the child to lie on the right side - correct answer d. Encourage the child to lie on the right side
12. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep, in which position should the nurse tell the parent to place the infant?
a. Side or prone
b. Back or prone
c. Stomach with the face turned
d. Back rather than on the stomach - correct answer d. Back rather than on the stomach
13. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?
a. "The immunization schedule will need to be altered."
b. "The child should not receive any hepatitis vaccines."
c. "The child will receive all of the vaccines except for the polio series."
d. "The child will receive the recommended basic series of immunizations alone with a yearly influenza vaccination." - correct answer d. "The child will receive the recommended basic series of immunizations alone with a yearly influenza vaccination."
14. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor which indication that the child may be experiencing an obstruction?
a. The child exhibits nasal flaring and bradycardia
b. The child is leaning forward with the chin thrust out
c. The child has a low-grade fever and complains of a sore throat
d. The child is leaning backward supporting themselves with the hands and arms - correct answer b. The child is leaning forward with the chin thrust out
15. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?
a. Tell the mother that the child must stay in the tent.
b. Place a toy in the tent to make the child feel more comfortable.
c. Call the health care provider and obtain a prescription for a mild sedative.
d. Let the mother hold the child and direct the cool mist over the child's face. - correct answer d. Let the mother hold the child and direct the cool mist over the child's face.
16. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?
a. Positive
b. Negative
c. Inconclusive
d. Definitive and requiring a repeat test - correct answer a. Positive
17. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?
a. "The child may be allergic to antibiotics."
b. "The child is too young to receive antibiotics."
c. "Antibiotics are not indicated unless a bacterial infection is present."
d. "The child still has the maternal antibodies from birth and does not need antibiotics." - correct answer c. "Antibiotics are not indicated unless a bacterial infection is present."
18. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
a. Initiate strict enteric precautions
b. Move the infant to a room with another child with RSV.
c. Leave the infant in the present room because RSV is not contagious.
d. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child. - correct answer b. Move the infant to a room with another child with RSV.
19. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which intervention should the nurse include in the plan of care? Select all that apply.
a. Place the infant in a private room
b. Ensure that the infant's head is in a flexed position
c. Wear a mask at all times when in contact with the infant
d. Place the infant in a tent that delivers warm humidified air
e. Position the infant on the side, with the head lower than the chest
f. Ensure that the nurses caring for the infant with RSV do not care for other high-risk children - correct answer a. Place the infant in a private room
f. Ensure that the nurses caring for the infant with RSV do not care for other high-risk children
20. The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings and documented in the record, knowing that which sign is most likely led the mother to seek health care for the infant?
a. Diarrhea
b. Projectile vomiting
c. Regurgitation of feedings
d. Foul smelling, ribbon like stools - correct answer d. Foul smelling, ribbon like stools
21. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
a. Prone position
b. On the stomach
c. Left lateral position
d. Right lateral position - correct answer c. Left lateral position
22. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
a. Incessant crying
b. Coughing at nighttime
c. Choking with feedings
d. Severe projectile vomiting - correct answer c. Choking with feedings
23. The nurse is providing feeding instructions to a parent of an infant with gastroesophageal reflux disease (GERD). Which instructions should the nurse give to the parent to reduce the episodes of emesis?
a. Provide less frequent, larger feedings
b. Burp the infant less frequently during feedings
c. Thing the feedings by adding water to the formula
d. Thicken the feedings by adding rice cereal to the formula - correct answer d. Thicken the feedings by adding rice cereal to the formula
24. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
a. Diarrhea
b. Metabolic acidosis
c. Metabolic alkalosis
d. Hyperactive bowel sounds - correct answer c. Metabolic alkalosis
25. The nurse is caring for a for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing which is the clinical manifestation associated with this disorder?
a. Bile-stained fecal emesis
b. The passage of currant jelly-like stools
c. Failure to pass meconium stool in the first 24 hours after birth
d. Sausage-shaped mass palpated in the upper right abdominal quadrant - correct answer c. Failure to pass meconium stool in the first 24 hours after birth
26. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which date would the nurse expect to obtain when asking the parent about the child's symptoms?
a. Watery diarrhea
b. Projectile vomiting
c. Increased urine output
d. Vomiting large amounts of bile - correct answer b. Projectile vomiting
27. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food in the child's diet?
a. Rice
b. Oatmeal
c. Rye toast
d. Wheat bread - correct answer a. Rice
28. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which signs of this disorder documented?
a. Watery diarrhea
b. Ribbon-like stools
c. Profuse projectile vomiting
d. Bright red blood and mucus in the stools - correct answer d. Bright red blood and mucus in the stools
29. Which interventions should the nurse include when creating a plan of care for a child with hepatitis? Select all that apply.
a. Providing a low-fat, well balanced diet
b. Teaching the child effective hand-washing techniques
c. Scheduling playtime in the playroom with other children
d. Notifying the health care provider if jaundice is present
e. Instructing the parents to avoid administering medication unless prescribed
f. Arranging for indefinite home schooling because the child will not be able to return to school - correct answer a. Providing a low-fat, well balanced diet
b. Teaching the child effective hand-washing techniques
e. Instructing the parents to avoid administering medication unless prescribed
30. The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
a. "I'm so glad they didn't find any protein in his urine."
b. "I noticed his urine was the color of coca-cola lately."
c. "His health care provider said his kidneys are working well."
d. "The nurse who admitted my child said his blood pressure was low." - correct answer b. "I noticed his urine was the color of coca-cola lately."
31. The nurse is performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common character is associated with this syndrome?
a. Hypertension
b. Generalized edema
c. Increased urinary output
d. Frank, bright red blood in the urine - correct answer b. Generalized edema
32. The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?
a. Restrict fluids as prescribed
b. Care for the arteriovenous fistula
c. Encourage foods high in potassium
d. Administer analgesics as prescribed - correct answer a. Restrict fluids as prescribed
33. A 7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents?
a. Primary nocturnal enuresis is caused by a psychiatric problem
b. Primary nocturnal enuresis does not respond to treatment
c. Primary nocturnal enuresis requires surgical intervention to improve the problem
d. Primary nocturnal enuresis is usually outgrown without therapeutic intervention - correct answer d. Primary nocturnal enuresis is usually outgrown without therapeutic intervention
34. The nurse provided discharge instructions to the parents of a 2-year-old who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates a need for further instruction?
a. "I'll check his temperature."
b. "I'll give him medication so he'll be comfortable."
c. "I'll check his voiding to be sure there's no problem."
d. "I'll let him decide when to return to his play activities." - correct answer d. "I'll let him decide when to return to his play activities."
35. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?
a. "Caution should be used when straddling the infant on the hip."
b. "Vital signs should be taken daily to check for bladder infection."
c. "Catheterization will be necessary when the infant does not void."
d. "Circumcision has been delayed to save tissue for surgical repair." - correct answer d. "Circumcision has been delayed to save tissue for surgical repair."
36. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?
a. Cover the bladder with petroleum jelly gauze
b. Cover the bladder with nonadherent plastic wrap
c. Apply sterile distilled water dressings over the bladder mucosa
d. Keep the bladder tissue dry by covering it with a dry sterile gauze - correct answer b. Cover the bladder with nonadherent plastic wrap
37. Which question should the nurse ask the parents of a child suspected of having glomerulonephritis?
a. "Did your child fall off a bike onto the handlebars?"
b. "Has the child had persistent nausea and vomiting?"
c. "Has the child been itching or had a rash anytime in the last week?"
d. "Has the child had a sore throat or a throat infection in the last few weeks?" - correct answer d. "Has the child had a sore throat or a throat infection in the last few weeks?"
38. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?
a. Hematuria
b. Proteinuria
c. Bacteriuria
d. Glucosuria - correct answer c. Bacteriuria
39. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.
a. Pallor
b. Edema
c. Anorexia
d. Proteinuria
e. Weight loss
f. Decreased serum lipids - correct answer a. Pallor [Show Less]