Nurse is reviewing lab results of a school age child 1 week postop following an open fracture repair. Which findings should nurse ID as indication of
... [Show More] potential complication?
a. Erythrocyte sedimentation rate 18 mm/hr
b. WBC count 6,200/mm3
c. C-reactive protein 1.4 mg/LRBC count 4.7 million/mm3
a. Erythrocyte sedimentation rate 18 mm/hr
- above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.
Wrong Answers:
b. WBC count 6,200/mm3:- within the expected reference range of 5,000 to 10,000/mm3.
-An elevated WBC count is an indication of osteomyelitis.
c. C-reactive protein 1.4 mg/L:- within the expected reference range of <10.0 mg/L.
-An elevated C-reactive protein level is an indication of osteomyelitis.RBC count 4.7 million/mm3:- within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage.
Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan?
a. Use sterile scissors to remove the dressing from the site.
b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use
c. Access the site using a noncoring angled needle
d. Use a semipermeable transparent dressing to cover the site
d. Use a semipermeable transparent dressing to cover the site
- The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.
Wrong Answers:
a. Use sterile scissors to remove the dressing from the site
- The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter.
b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use
- The nurse should flush each lumen of the catheter with a heparin solution daily when not in use.
c. Access the site using a noncoring angled needle
- The nurse should use a noncoring angled or straight needle when accessing an implanted port.
Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans?
a. Administer pancreatic enzymes 2 hr after meals.
b. Discontinue the use of pancreatic enzymes if steatorrhea develops.
c. Limit fluid intake to 750 mL per day.
d. Increase fat content in the child's diet to 40% of total calories.
d. Increase fat content in the child's diet to 40% of total calories
- A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.
Wrong Answers:
a. Administer pancreatic enzymes 2 hr after meals
- The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis.
b. Discontinue the use of pancreatic enzymes if steatorrhea develops
- A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves.
c. Limit fluid intake to 750 mL per day
- The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration.
Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what?
a. Wheezes
b. Crackles
c. Pleural friction rub
d. Rhonchi
a. Wheezes
- high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways.
Wrong answers:
b. Crackles
- high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted.
c. Pleural friction rub
- a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together.
d. Rhonchi
- low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.
Nurse assesses school age child with infratentorial brain tumor. Which findings should the nurse ID as manifestation of IICP?
a. Hypotension
b. Reports insomnia
c. Difficulty concentrating
d. Tachycardia
c. Difficulty concentrating
- The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of IICP due to decreased blood flow within the brain and pressure on the brainstem.
Wrong Answers:
a. Hypotension
- HTN is a late manifestation of IICP due to compression of the brain vessels.
b. Reports insomnia
- somnolence and lethargy are manifestations of IICP.
c. Tachycardia
- bradycardia is a late manifestation of IICP.
Nurse assesses infant with pneumonia. Which findings is priority for nurse to report to HCP?
a. Nasal flaring
b. WBC count 11,300/mm3
c. Diarrhea
d. Abdominal distension
a. Nasal flaring
- When using the ABC approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.
Wrong Answers:
b. WBC count 11,300/mm3
- The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report.
c. Diarrhea
- The nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.
d. Abdominal distension
- The nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.
Nurse in health department is caring for emancipated adolescent with STI and unaccompanied by guardian. Which actions should the nurse take?
a. Have the adolescent sign a consent form for treatment.
b. Instruct the adolescent to return with a guardian.
c. Obtain consent from the adolescent's guardian over the phone
d. Treat the adolescent without a consent form
a. Have the adolescent sign a consent form for treatment
- The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.
Nurse teaches adolescent about how to manage tinea pedis. Which statements by adolescent indicates understanding of teaching?
a. "I should buy plastic shoes to wear at the swimming pool."
b. "I should wear sandals as much as possible."
c. "I should place the permethrin cream between my toes twice daily."
d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
b. "I should wear sandals as much as possible."
- Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow.
-The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.
Nurse assesses 8 y/o child with early indications of shock. After establishing airway and stabilizing child's resp, which actions should the nurse take next?
a. Insert an indwelling urinary catheter.
b. Measure weight and height.
c. Initiate IV access.
d. Maintain ECG monitoring.
c. Initiate IV access
- After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the ABC approach to client care is to establish IV access to maintain the child's circulatory volume.
Wrong Answers:
a. Insert an indwelling urinary catheter
- The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because UO decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first.
b. Measure weight and height
- The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first.
c. Maintain ECG monitoring
- The nurse should maintain ECG monitoring for a child who has early indications of shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first.
Charge nurse prepares to make room assignment for newly admitted school age child. Which considerations is the nurse's priority?
a. Length of stay
b. Treatment schedule
c. Disease process
d. Self-care ability
c. Disease process
- The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration.
Wrong answers:
a. Length of stay
- some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration.
b. Treatment schedule
- children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.
d. Self-care ability
- children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.
Nurse in ED assesses 3 month old infant with rotavirus and experiences acute vomiting and diarrhea. Which manifestations should nurse ID as indication that infant has moderate to severe dehydration?
a. Heart rate 124/min
b. Increased tear production
c. Sunken anterior fontanel
d. Cap refill 2 secs
c. Sunken anterior fontanel
- The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid.
Wrong answers:
a. Heart rate 124/min
- within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia.
b. Increased tear production
- An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production.
d. Capillary refill 2 sec
- within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.
A nurse is preparing to administer ibuprofen 5mg/kg every 6 hours prn for temperatures above 38.0 C (100.5 F) to an infant that weighs 17.6 Lb. The infant has a temperate of 38.4 C (101.2 F). Available is ibuprofen liquid 100mg/5mL. How many mL should the nurse administer to the infant per dose? round to the nearest whole number. Use a leading 0 if it applies.
2 mL
Nurse provides dietary teaching to guardian of school age child with cystic fibrosis. Which statements should nurse make?
a. "You should offer your child high-protein meals and snacks throughout the day."
b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake."
c. "You should restrict your child's calorie intake to 1,200 per day."
d. "You should give your child a multivitamin once weekly."
ANS: "You should offer your child high-protein meals and snacks throughout the day.":- The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection."You should decrease your child's dietary fat intake to less than 10% of their caloric intake.":- Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines."You should restrict your child's calorie intake to 1,200 per day.":- Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day."You should give your child a multivitamin once weekly.":- Children who have cystic fibrosis should be given a multivitamin once daily.
Nurse reviews dietary choices of adolescent with iron deficiency anemia. Nurse should ID which menu items has highest amount of nonheme iron?½ cup whole milk1 cup orange juice1/2 cup raisins1 cup raw carrots
ANS: ½ cup raisins:- The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron.
1 cup orange juice:- Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body.
Nurse provides discharge teaching to parents of 6 month old infant postop following hypospadias repair with stent placement. Which instructions should the nurse include in teaching?"You may bathe your infant in an infant bathtub when you go home.""Apply hydrocortisone cream to your infant's penis daily.""You should clamp your infant's stent twice daily.""Allow the stent to drain directly into your infant's diaper."
ANS: "Allow the stent to drain directly into your infant's diaper.":- The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow.
"You may bathe your infant in an infant bathtub when you go home.":- Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent."Apply hydrocortisone cream to your infant's penis daily.":- Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection."You should clamp your infant's stent twice daily.":- The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant.
Nurse in ED cares for school age child with epiglottis. Which actions should the nurse take?Obtain a throat culture from the child.Monitor the child's oxygen saturation.Put a warm mist humidifier in the child's room.Place the child in the supine position.
ANS: Monitor the child's oxygen saturation:- The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment.
Obtain a throat culture from the child:- Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing.Put a warm mist humidifier in the child's room:- The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room.Place the child in the supine position:- Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.
Nurse in HCP office is caring for school age child with varicella. Parent asks nurse when their child will no longer be contagious. Which response should the nurse make?"When your child no longer has an increased temperature.""Three days after you first noticed the rash appear on your child.""When your child's lesions are crusted, usually 6 days after they appear.""Two to three weeks, when your child's lesions completely disappear."
ANS: "When your child's lesions are crusted, usually 6 days after they appear.":- The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.
"When your child no longer has an increased temperature.":- The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious."Three days after you first noticed the rash appear on your child.":- The nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears.
"Two to three weeks, when your child's lesions completely disappear.":- The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions.
Nurse teaches family of school age child with juvenile idiotpathic arthritis. Which instructions should the nurse include in teaching?"Limit movement of the child's large joints.""Encourage the child to perform independent self-care.""Provide the child with a soft mattress for sleeping.""Schedule a 2-hour daily nap for the child in the afternoon."
"Limit movement of the child's large joints.":- Large joints should be exercised regularly to maintain mobility and strengthen muscles.ANS: "Encourage the child to perform independent self-care.":- The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem."Provide the child with a soft mattress for sleeping.":- Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position."Schedule a 2-hour daily nap for the child in the afternoon.":- Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleep
School nurse provides in service for faculty about improving education for students with ADHD. Which statements by faculty member indicates understanding of teaching?"I will plan to increase the amount of homework I assign to students who have ADHD.""I will give students who have ADHD the same amount of time as other students to complete tests.""I will allow students who have ADHD one rest break throughout the day.""I will teach challenging academic subjects to students who have ADHD in the morning."
ANS: "I will teach challenging academic subjects to students who have ADHD in the morning.":- Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.
"I will plan to increase the amount of homework I assign to students who have ADHD.":- Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention."I will give students who have ADHD the same amount of time as other students to complete tests.":- Students who have ADHD should be given additional time to take tests due to decreased attention."I will allow students who have ADHD one rest break throughout the day.":- Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment. [Show Less]