How to administer antibiotic eardrops
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A nurse is teaching the parents of an infant how to administer antibiotic
eardrops. Which of the following instructions should the nurse include in
the teaching?
Chill the medication prior to administration.
The nurse should instruct the parents that the otic solution should be at
room temperature before instilling in the ear to minimize discomfort.
Pull the pinna up and back during medication administration.
The nurse should instruct the parents to gently pull the pinna downward and
straight back during administration of the medication to the infant. This
positions the ear canal and eustachian tube to ensure correct placement of
the medication.
Hyperextend the infant's neck during medication administration.
The nurse should not instruct the parents to hyperextend the infant's neck
when administering ear drops, as this is the position used to administer
nasal medications. The nurse should instruct the parents to turn the
infant's head to the appropriate side while in the prone or supine
position. After instilling the medication, the parents should keep the
infant in a lateral position for a few minutes to ensure the medication
reaches the target area.
Massage the anterior area of the ear following administration.
MY ANSWER
The nurse should instruct the parents to massage the anterior area of the
ear, just in front of the tragus, following administration to facilitate
instillation of the medication into the ear canal. This action assists the
medication in reaching the target area.
A nurse is providing a presentation for parents of a toddler about
preventing childhood burns. Which of the following statements by a parent
indicates an understanding of the teaching?
"I will change the batteries in our smoke detectors every 24 months."
Parents should change the batteries in their smoke detectors 1 to 2 times a
year to ensure the devices function properly and continuously.
"I will turn pot handles turned toward me when I am cooking."
Parents should keep pot handles turned toward the back of the stove at all
times to prevent the toddler from pulling down on the handles and spilling
hot contents, inflicting serious burns.
"I don't need to apply sunscreen to my child if he is outside after 3 p.m.”
Parents should apply sunscreen of SPF 15 or greater whenever children are
outdoors. The nurse should suggest the parents keep children indoors during
10 a.m. to 2 p.m. when the risk for sunburns is the greatest.
"I will plug protective guards into my electrical outlets."
MY ANSWER
Parents should plug protective guards into electrical outlets or place
furniture in front of the outlets to protect the toddler from electrical
shock or burns.
3. A nurse is teaching a group of new parents about expected language
development. The nurse should include that a child should begin to speak 10
or more words about which of the following ages?
6 months
The nurse should expect infants to begin adding consonants to simple
syllables (“da-da,wa-wa”) and begin to imitate sounds around 6 months of
age.
10 months
The nurse should expect an infant to begin speaking their first words with
meaning around 10 months of age.
18 months
MY ANSWER
The nurse should expect a toddler to speak 10 or more words around 18
months of age. The toddler should also form simple word combinations.
24 months
The nurse should expect a toddler to speak approximately 300 words around
24 months of age. The toddler should also use two- and three-word phrases
and pronouns.
4. A nurse in the emergency department is caring for a preschool-age child
who has hemophilia A and sustained an abdominal trauma following a motor
vehicle crash. Which of the following actions should the nurse take?
(Select all that apply.)
Administer factor VIII.
Assess for changes in level of consciousness.
Apply a warming blanket over the child.
Perform passive range of motion hourly.
Administer factor IX.
MY ANSWER
Administer factor VIII is correct. Hemophilia A is a bleeding disorder
caused by a factor VIII deficiency; therefore, the nurse should plan to
administer factor VIII prophylactically to prevent or minimize bleeding.
Assess for changes in level of consciousness is correct. Hemophilia A can
cause cerebral bleeding; therefore, the nurse should assess the child for
headaches and decreased level of consciousness.
Apply a warming blanket over the child is incorrect. The nurse should apply
ice or cold packs to the child to vasoconstrict the child's blood flow.
Perform passive range of motion hourly is incorrect. The nurse should rest
the joints during the acute phase of bleeding to prevent stretching the
joint or bleeding to recur.
Administer factor IX is incorrect. The nurse should identify that children
who have hemophilia B have a deficiency in factor IX and the nurse should
plan to administer factor IX prophylactically to prevent or minimize
bleeding.
5.
A nurse is creating a plan of care for a school-age child who has moderate
partial-thickness burns on both lower extremities. Which of the following
interventions should the nurse include in the plan?
Maintain aseptic technique during the child's dressing changes.
The nurse should perform dressing changes using aseptic technique to
prevent infection. Delayed wound healing can occur due to infection, which
can also cause partial-thickness wounds to develop into full-thickness
wounds.
Provide low-calorie snacks for the child several times each day.
Burn injuries create a hypermetabolic state, requiring an increase of up to
three times the normal calorie requirements. The nurse should provide
high-calorie, high-protein snacks to promote healing and replace calories
and proteins that are expended due to the child's increased metabolism.
Apply continuous passive motion devices to the child's lower extremities
during periods of rest.
The nurse should apply splints to the child's lower extremities during
periods of rest and sleep to minimize the development of flexion
contractions.
Administer pain medication to the child 30 min following physical therapy.
MY ANSWER
The nurse should administer pain medication to the child 30 to 45 min prior
to painful procedures, such as physical therapy or dressing changes.
Adequate pain control is needed so the child will actively participate and
cooperate during physical therapy.
6.
A nurse is performing an initial physical examination on a child. The nurse
should recognize that which of the following manifestations indicates a
possible brain tumor? (Select all that apply.)
Vomiting
Bruises easily
Clumsiness
Irritability
Persistent headaches
MY ANSWER
Vomiting is correct. The clinical manifestations of a brain tumor vary with
the size and location of the tumor. Vomiting unrelated to feeding is a
common finding. It tends to become progressively more projectile and is
most severe in the morning. It can be accompanied by nausea and is a result
of increased intracranial pressure.
Bruises easily is incorrect. Anticoagulation is not associated with brain
tumors. It is more likely to be seen with hematologic malignant disease
(leukemia).
Clumsiness is correct. Clumsiness, lack of coordination, and loss of
balance are common manifestations of brain tumors. Manifestations result
from pressure and interference with circulation within the brain.
Irritability is correct. Irritability is a common behavioral manifestation
of brain tumors. Other manifestations include anorexia, fatigue, lethargy,
and bizarre behavior such as staring.
Persistent headaches is correct. Headache is probably the most common
symptom of brain tumors. Headaches result from pressure on pain-sensitive
areas, such as large blood vessels and cranial nerves. Headaches tend to be
worse in the morning and subside as the day progresses.
7. A nurse is documenting a male infant's weight on a growth chart. The
infant is 11 months old and weighs 11.3 kg (24.9 lb). Identify the correct
point on the graph where the nurse should plot the infant's weight. (You
will find hot spots to select in the artwork below. Select only the hot
spot that contains the plot point that corresponds to your answer.)
A is correct. To document the appropriate area on the growth chart, obtain
a chart designated for the infant's age and sex. Next, the nurse should
find the marker for age at the bottom of the chart. Then, on the right side
of the page, the nurse should determine the marker for weight in either kg
or lb and plot them on the graph accordingly. If the points plotted are
within the two bolded lines, representing the 10th and 95th percentiles,
the child's development in terms of these parameters is appropriate. This
is the correct documentation of the infant's weight.
B is incorrect. To document the appropriate area on the growth chart,
obtain a chart designated for the infant's age and sex. Next, the nurse
should find the marker for age at the bottom of the chart. Then, on the
right side of the page, the nurse should determine the markers for weight
in either kg or lb and plot them on the graph accordingly. According to
this point on the chart, the infant is 13 months old and weighs 11.3 kg
(24.9 lb).
C is incorrect. To document the appropriate area on the growth chart,
obtain a chart designated for the infant's age and sex. Next, the nurse
should find the marker for age at the bottom of the chart. Then, on the
right side of the page, the nurse should determine the markers for weight
in either kg or lb and plot them on the graph accordingly. According to
this point on the chart, the infant is 11 months old and weighs 9.5 kg
(20.9 lb).
D is incorrect. To document the appropriate area on the growth chart,
obtain a chart designated for the infant's age and gender. Next, the nurse
should find the marker for age at the bottom of the chart. Then, on the
right side of the page, the nurse should determine the markers for weight
in either kg or lb and plot them on the graph accordingly. According to
this point on the chart, the infant is 13 months old and weighs 10.2 kg
(22.5 lb).
8.
A nurse is providing discharge teaching to a group of guardians of infants
about home safety. Which of the following statements should the nurse make?
"Place your baby in a side-lying position when sleeping."
The nurse should instruct the parents to avoid placing the infant in a
side-lying position unless medically indicated. All infants should be
placed in supine position to decrease the risk for sudden infant death
syndrome (SIDS).
"Use a drop-side crib until your baby is at least 6 months old."
MY ANSWER
The nurse should instruct the parents to avoid the use of drop-side cribs
due to increased risk for falls and potential injury.
"Apply a plastic mattress cover to your baby's bed to protect it."
The nurse should instruct the parents to avoid using plastic on the
infant's mattress because it can cause suffocation.
"Keep your infant restrained when they are in a highchair."
The nurse should instruct the parents to restrain their infant while
sitting in a highchair using the included strap with a closure. This will
prevent the infant from falling out of the chair and decrease the risk for
injury. The nurse should also instruct the parents to avoid leaving their
infant in a highchair unattended because of the risk of slipping down in
the chair and strangling on the safety strap.
9.
A nurse is preparing to administer erythromycin 50 mg/kg/day in divided
doses every 6 hr to an adolescent who is postoperative following surgical
removal of a peritonsillar abscess and weighs 40 kg. Available is
erythromycin oral solution 200 mg/5 mL. How many mL should the nurse
administer with each dose? (Round the answer to the nearest tenth. Use a
leading zero if it applies. Do not use a trailing zero.)
12.5 ml
10.
A nurse is teaching the parent of a school-age child who has cystic
fibrosis about home care. Which of the following statements by the parent
indicates an understanding of the teaching?
"I will cook foods that are low in fat and carbohydrates."
The parent should serve nutritious foods that are high in calories,
protein, and fats. A child who has cystic fibrosis experiences intestinal
malabsorption and is at risk for nutritional deficiencies and inadequate
growth.
"My child can chew their enzyme medication with meals."
The parent should have the child swallow the capsules whole or sprinkle
them on their food within 30 min of their meals and snacks. The child
should not chew or crush the enteric-coated tablets, because destroying the
enteric coating can lead to inactivation of the enzymes and excoriation of
the oral mucosa.
"I will give my child stool softeners for constipation."
MY ANSWER
Constipation can occur in the child who has cystic fibrosis because of a
failure to properly break down foods, a slowing of the intestinal motility,
and the thickened enzymatic secretions due to the disease process itself.
The parent should administer an osmotic solution, such as polyethylene
glycol, stool softeners, or laxatives to treat constipation.
"My child will be excused from physical education class."
The parent should encourage the child to participate in physical exercise
to mobilize secretions and increase blood flow to the lungs. Exercise can
stimulate mucus excretion and provides a sense of good health and positive
self-esteem for the child.
11.
A nurse is assessing an infant who has Tetralogy of Fallot. Which of the
following clinical manifestations should the nurse expect? (Select all that
apply.)
Anemia
Stridor
Bounding peripheral pulses
A heart murmur
Cyanotic spells
MY ANSWER
Anemia is incorrect. Tetralogy of Fallot is four defects that alter
hemodynamics to widely varying degrees. Shunting can be in either direction
depending on the degree of the defects and the differences between the
pulmonary and the systemic vascular resistance. The chronic hypoxemia
stimulates erythropoiesis, resulting in polycythemia, which is an increased
number of RBCs.
Stridor is incorrect. Stridor, a noisy, high-pitched respiration, is not a
clinical manifestation of Tetralogy of Fallot.
Bounding peripheral pulses is incorrect. Bounding peripheral pulses are not
a clinical manifestation of Tetralogy of Fallot.
A heart murmur is correct. Infants who have Tetralogy of Fallot exhibit a
systolic murmur that is moderate in intensity.
Cyanotic spells is correct. Infants who have Tetralogy of Fallot experience
anoxic spells when the infant's oxygen requirements exceed the oxygen
available in the blood supply, such as when the infant is crying or
following a feeding.
12.
A nurse is providing home care instructions to the parents of a child who
is in the edema phase of nephrotic syndrome. Which of the following
instructions should the nurse include in the teaching?
Restrict the child's potassium intake.
MY ANSWER
The nurse should not instruct the parents to restrict the child's potassium
intake. However, the parents should restrict the child's sodium intake by
avoiding the addition of salt to the child's food, and by eliminating
high-sodium foods from the diet. The child may resume a regular salt intake
after the acute phase of nephrotic syndrome has passed.
after the acute phase of nephrotic syndrome has passed.
Provide quiet activities for the child.
The nurse should instruct the parents to provide quiet activities, such as
reading and coloring, during the edema phase of nephritis to minimize
oxygen consumption and preserve energy.
Weigh the child once a week.
The nurse should instruct the parents to weigh the child at the same time
each day with the child wearing the same clothing. The nurse should
instruct the parents to notify the provider if the child's weight
increases.
Administer acetaminophen to the child daily.
The nurse should not instruct the parents to administer acetaminophen to
the child daily. Daily administration of acetaminophen could also cause
additional stress to the child's kidneys.
13.
A nurse is providing discharge teaching to the parents of a school-age
child who has epilepsy and a new prescription for phenytoin
extended-release capsules. Which of the following instructions should the
nurse include in the teaching?
Administer the medication on an empty stomach.
MY ANSWER
The nurse should instruct the parents to administer the medication with
meals, or just before eating, to prevent gastrointestinal upset.
Encourage the child to brush their teeth after each meal.
The nurse should recommend consistent dental hygiene to the parents of a
child who has a prescription for phenytoin. This medication can cause
gingival hyperplasia, and good oral hygiene reduces the risk of this
occurring.
Crush the child's medication to mix with applesauce.
The nurse should instruct the parents to administer the extended-release
capsule whole to ensure proper absorption and therapeutic plasma drug
levels.
Observe the child for diarrhea.
The nurse should instruct the parents to monitor the child for constipation
as an adverse effect of phenytoin.
14.
A nurse is caring for a 3-year-old child who has viral meningitis. Which of
the following findings should the nurse expect?
Koplik spots
The nurse should not expect a child who has viral meningitis to have Koplik
spots. Koplik spots are small red spots with a white center that are found
on the oral mucosa in children who have measles.
Decreased protein in the cerebrospinal fluid
The nurse should expect a child who has viral meningitis to exhibit either
a normal or slightly elevated protein level in the cerebrospinal fluid due
to increased permeability of the blood-brain barrier.
Nuchal rigidity
MY ANSWER
The nurse should expect a child who has viral meningitis to have nuchal
rigidity, which is caused by meningeal irritation. The child also might
have fever and photophobia.
Decreased glucose in the cerebrospinal fluid
The nurse should expect a child who has viral meningitis to exhibit a
glucose level within the expected reference range in the cerebrospinal
fluid. Bacterial meningitis can decrease the glucose in the cerebrospinal
fluid.
15.
A nurse is assessing a 4-month-old infant at a well-child visit. Which of
the following findings should the nurse expect?
The infant exhibits a fear of strangers.
The nurse should expect a 6-month-old infant to exhibit a fear of strangers
when the ability to recognize their parents develops.
The infant understands the word "no."
The nurse should expect a 9-month-old infant to understand the word "no"
and to respond to basic commands from their parents.
The infant has an absent grasp reflex.
The nurse should expect a 4-month-old infant to have an absent grasp reflex
because this primitive reflex disappears at 3 months of age. The nurse
should expect the infant to grasp objects with both hands at this stage of
development.
The infant rolls from their back to their abdomen.
MY ANSWER
The nurse should expect a 6-month-old infant to reposition from a supine
position to a prone position. At 4 months old, the infant should be able to
roll from their back to their side.
16.
16.
A nurse is assessing a child who has full-thickness burns of the legs.
Which of the following manifestations should the nurse expect?
Fluid-filled blisters
The nurse should not expect a full-thickness burn to have blisters.
Partial-thickness burns involve the epidermis and upper layers of the
dermis and are light pink to pink in color with denuded moist areas or
intact blisters. These burns are characteristically very painful.
Injured skin is cream to black in color
The nurse should expect a full-thickness burn to have variable colors,
including cream to brown or black. The injury reaches through the epidermis
to the dermis, and possibly to the muscles, tendons, and bone. Areas with a
full-thickness burn are less painful than partial-thickness burned areas
because of the nerve destruction involved.
Injured skin blanches with pressure
The nurse should not expect a full-thickness burn to blanche with pressure.
The surface of the burned skin will be dry, appear charred, and will not
blanche with pressure. Superficial thickness and partial-thickness burns
will blanche.
Intense, continuous pain
MY ANSWER
The nurse should not expect a full-thickness burn to cause intense,
continuous pain. Areas with a full-thickness burn involve nerve
destruction, limiting the sensation of pain.
17.
A nurse is planning care for a child who has cerebral palsy and is
experiencing muscle spasms. Which of the following medications should the
nurse expect to administer?
Indomethacin
The nurse should not plan to administer indomethacin to a child who has
cerebral palsy and is experiencing muscle spasms. Indomethacin is an
anti-inflammatory medication used in the treatment of gout.
Baclofen
MY ANSWER
The nurse should plan to administer baclofen to a child who has cerebral
palsy and muscle spasms because it is a centrally acting skeletal muscle
relaxant that will decrease muscle spasms and severe spasticity.
Methotrexate
The nurse should not plan to administer methotrexate to a child who has
cerebral palsy and is experiencing muscle spasms. Methotrexate is an
antineoplastic medication used to treat various cancers and rheumatoid
arthritis.
Carbamazepine
The nurse should not plan to administer carbamazepine to a child who has
cerebral palsy and is experiencing muscle spasms. Carbamazepine is an
anticonvulsant used to treat seizures.
PAUSE
18.
A nurse is providing teaching about magnetic resonance imaging (MRI)
without contrast to the parent of a child who has cancer. Which of the
following statements should the nurse make?
"Your child will be exposed to a moderate amount of radiation during the
procedure."
MY ANSWER
An MRI produces radiofrequency emissions from nonradioactive elements.
Therefore, the child is not exposed to radiation during this procedure
"Your child might experience pain during the procedure."
An MRI does not cause pain, as it is a noninvasive procedure that emits
radiofrequencies to produce an image.
"This is considered an invasive procedure."
An MRI is a noninvasive procedure, unless an IV is prescribed when contrast
is used. No contrast is indicated for this child, so no IV is needed.
"You can remain in the room with your child during the procedure."
The parent may remain in the room with the child to provide comfort and
reassurance during the procedure.
19.
A nurse is providing discharge teaching to the parents of a school-age
child who is immobilized following spinal surgery. Which of the following
nutritional recommendations should the nurse include?
Add supplemental calcium to the child's diet.
The nurse should not instruct the parents to increase the child's calcium
intake. Immobilization increases the risk for hypercalcemia, leading to
renal stones, muscle fatigue, and diminished reflexes.
Decrease dietary fiber intake.
The nurse should not instruct the parents to decrease the child's intake of
fiber. Immobilization increases the risk for constipation and fecal
impaction. Therefore, the nurse should instruct the parents to increase the
child's fiber intake.
Encourage small, frequent meals high in protein.
MY ANSWER
The nurse should instruct the parents to provide small but frequent meals
that are high in protein while their child is healing from surgery.
Immobilization causes a decrease in appetite. Therefore, small but frequent
meals will be more readily tolerated. Adequate protein intake is needed for
energy and tissue healing.
Encourage foods that are low in calories.
The nurse should not instruct the parents to provide foods that are low in
calories. Immobilization decreases the metabolic rate and appetite.
However, adequate healing requires calories to prevent undernutrition,
nutrient deficiencies, and a negative nitrogen balance. The nurse should
instruct the parents to provide nutrient-dense foods that are high in
protein.
A nurse in an emergency department is providing pre-procedure teaching to
the parents of a child who is to undergo a bronchoscopy due to aspiration
of a foreign body. Which of the following parent statements indicate
understanding of the teaching?
"My child will be awake for this procedure."
The child requires sedation for an endoscopy and bronchoscopy to prevent
complications from this procedure. Therefore, the child will not be awake
during the procedure.
"I can take my child home as soon as the procedure is over."
The nurse will observe the child for complications, such as laryngeal
edema, after the procedure. The child can go home when their vital signs
are stable and he has a gag/cough reflex, which usually returns within a
few hours.
"The provider will remove the object during this procedure."
MY ANSWER
The provider is able to make a definitive diagnosis of objects in the
larynx and trachea during a bronchoscopy and can subsequently remove the
foreign body.
"After this procedure, I have to wait 48 hours before I can give my child
solid foods."
Once the gag/cough reflex returns, the child can consume fluids and solid
foods. This usually occurs within a few hours following the procedure.
21.
A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of
the following findings should the nurse identify as a manifestation of
severe dehydration?
Flat anterior fontanel
The nurse should identify a flat anterior fontanel as an expected finding
in an infant who has mild dehydration. An infant who has moderate to severe
dehydration will exhibit a sunken anterior fontanel.
Dry, hot skin
The nurse should observe that an infant who is severely dehydrated has skin
that is cool to the touch and mottled in appearance with the presence of
tenting.
Loss of 5% of weight
The nurse should identify a loss of 5% of weight as a manifestation of mild
dehydration. An infant experiencing a 6% to 9% weight loss has moderate
dehydration, while a loss of 10% or more indicates severe dehydration.
Absence of tears when crying
MY ANSWER
The nurse should identify the absence of tears when crying as a
manifestation of severe dehydration. Other manifestations of severe
dehydration include: sunken eyeballs, parched mucous membranes, oliguria,
sunken fontanels, and hyperpnea.
A school nurse is providing dietary teaching for an 11-year-old child who
has type 1 diabetes mellitus. The nurse should identify which of the
following responses by the child indicates an understanding of the
teaching? (Select all that apply.)
"I should eat extra food on busy days when I am more active."
"I should wait 2 hours after eating before playing with my friends."
"I should increase my intake of sugar-free fluids when I am sick."
"I should eat a snack 30 minutes before my baseball game starts."
"I should have a 16 ounce glass of milk if I start feeling weak or shaky."
MY ANSWER
"I should eat extra food on busy days when I am more active" is correct.
The nurse should instruct the child to increase their intake of allowable
foods when they are more active. Exercise lowers blood glucose levels
during and after activity. Food intake should be adjusted to compensate for
the release of insulin into the circulatory system and prevent episodes of
hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per
hour of moderate play or activity.
"I should wait 2 hours after eating before playing with my friends" is
incorrect. The child should play or exercise within 2 hr of eating because
exercise requires them to have more carbohydrates in their system. Waiting
2 hr after eating before play or exercise increases the likelihood of a
hypoglycemic episode. A carbohydrate snack will most likely be needed
during prolonged play or exercise and another a few hours after the
activity.
"I should increase my intake of sugar-free fluids when I am sick" is
correct. The nurse should instruct the child to increase their intake of
sugar-free fluids when they are sick. Fluids flush out ketones to prevent
dehydration. The nurse should recommend sugar-free liquids, such as water,
broth, and tea to the child. The child should continue with their usual
intake at mealtimes and follow their recommended meal plan as much as
possible.
"I should eat a snack 30 minutes before my baseball game starts" is
correct. The nurse should instruct the child to eat a recommended snack 30
min prior to a planned activity, such as a baseball game. If the game is
prolonged, they should have a snack every 45 min to an hour. If for some
reason the child cannot tolerate the extra food, the next intervention is
to decrease the child's insulin dose before baseball games.
"I should have a 16 ounce glass of milk if I start feeling weak or shaky."
is incorrect. The child should consume 8 oz of milk if they feel
hypoglycemic, rather than 16 oz. Clinical manifestations of hypoglycemia
include dizziness, headache, irritability, weakness, shakiness, and
confusion. An 8-oz glass of milk contains 15 g of carbohydrate. If the
child consumes 16 oz, it would contain a minimum of 30 g of carbohydrate
and most likely cause the child to become hyperglycemic and require a dose
of insulin.
23.
A nurse is assessing a toddler. Which of the following findings should the
nurse identify as an indication of potential child maltreatment?
Superficial scrapes on the toddler's lower legs
The nurse should identify that superficial scrapes on the child's lower
legs are an expected finding for a toddler. Due to immature motor skills
and their physical activity level, toddlers often bump into objects and
fall, leading to superficial scrapes and bruising on the extremities.
Circular burns on the soles of the toddler's feet
MY ANSWER
The nurse should identify circular burns on the soles of the toddler's feet
as a potential indication of child maltreatment. Physical manifestations of
burns are often found on the soles, back, buttocks, or hands. The nurse
should document the location of the burns along with a description of the
pattern and the presence of eschar or blistering. The nurse should also
obtain diagrams and photographs using a measurement tool.
Irregular area of blue pigmentation over the toddler's sacrum
The nurse should identify an irregular area of blue discoloration over the
toddler's sacrum as a Mongolian spot. This discoloration is not a
manifestation of child maltreatment and most often occurs in children who
have darker skin tones (American Indian, Hispanic, Asian, and African
American).
Single bruise on the toddler's forearm
The nurse should identify a single bruise on the toddler's forearm as an
expected finding for a toddler. Due to immature motor skills and their
physical activity level, toddlers often bump into objects and fall, leading
to superficial scrapes and bruising on the extremities.
A nurse is caring for a child who has bacterial meningitis. Which of the
following actions should the nurse take first?
Administer IV antibiotics.
The nurse should administer IV antibiotics to the child to eliminate the
infectious organism. However, evidence-based practice indicates another
action is the priority.
Monitor vital signs.
The nurse should closely monitor the child's vital signs because the child
can develop a shock state or develop a fever. However, evidence-based
practice indicates another action is the priority.
Encourage oral fluids.
The nurse should encourage oral fluid intake to maintain hydration.
However, evidence-based practice indicates another action is the priority.
Initiate droplet precautions.
MY ANSWER
According to evidence-based practice, the nurse should first initiate
droplet isolation precautions to reduce the risk of transmission of the
infection to others.
25.
A home health nurse is developing a plan of care for the parents of a
toddler who has hemophilia A. Which of the following instructions should
the nurse include?
Administer aspirin for pain.
The nurse should not instruct the parents to administer aspirin to the
toddler, because aspirin has anti-platelet actions that increase the risk
of bleeding. The nurse should instruct the parents to administer
acetaminophen if the child experiences pain.
Place knee pads on the child.
MY ANSWER
As toddlers grow and explore, it is important that parents of a child who
has hemophilia take measures to make the environment safe. This can include
measures such as installing carpeting over ceramic tiled floors or placing
knee and elbow pads on the child to protect the child's joints from injury
and bleeding.
Perform passive range-of-motion exercises following an acute episode.
The nurse should instruct the parents to allow the child to move their
joints on their own as they can gauge at which point the pain increases.
The parents should also avoid performing passive range-of-motion exercises
for their child because this can increase the risk of bleeding in the
joint.
Use a firm-bristled toothbrush for dental care.
The nurse should instruct the parents of the child to use a soft-bristled
toothbrush when providing oral care to the toddler to avoid bleeding and
minimize oral trauma. Soft foam oral swabs that are disposed of after use
can also be used.
26.
A nurse is planning care for a newly admitted child who has autism spectrum
disorder. Which of the following interventions should the nurse include in
the plan?
Establish a reward system for the child.
MY ANSWER
Children, including those who have autism spectrum disorder, respond to
positive reinforcement. Therefore, the nurse should establish a reward
system with the child to help facilitate acceptable behavior. This helps to
promote a therapeutic environment for the child.
Limit parent visits with the child.
Children who have autism spectrum disorder require consistency, including
having access to their parent. The nurse should encourage the parents to
spend as much time as possible with the child to decrease fear and anxiety,
promoting a therapeutic environment for the child.
Keep the door to the child's room open.
Children who have autism spectrum disorder have difficulty with social
interaction and experience increased anxiety with overstimulation. The
nurse should provide a therapeutic environment by placing the child in a
quiet environment and maintaining the door of the child's room closed
whenever possible.
Leave a television on during the night.
Children who have autism spectrum disorder can become agitated and anxious
when they are exposed to auditory and visual stimulation. The nurse should
provide a therapeutic environment by limiting extraneous environmental
stimuli such as a television or radio. Leaving these devices on during the
night have the additional effect of decreasing rest during sleep.
27.
A nurse is planning care for an infant who has respiratory syncytial virus
(RSV) and a respiratory rate of 46/min. Which of the following
interventions should the nurse include in the plan of care?
Initiate contact precautions.
MY ANSWER
The nurse should initiate contact, droplet, and standard precautions for
RSV because exposure to contaminated secretions can transmit the virus. RSV
can live on objects for several hours and on hands for 30 min.
Perform chest percussion and postural drainage.
The nurse should perform periodic suctioning of the nose or nasopharynx to
clear nasal secretions. Chest percussion and postural drainage are not
routinely recommended for an infant who has RSV.
Encourage clear liquids by mouth.
The nurse should not encourage clear liquids by mouth because the infant
has tachypnea. Oral fluids are contraindicated in the presence of tachypnea
due to the risk for aspiration.
Administer IV antibiotics.
The nurse should not plan to administer IV antibiotics because RSV is a
viral infection. Antibiotics might be prescribed if a secondary bacterial
infection occurs.
28.
A charge nurse on a pediatric unit is reviewing informed consent guidelines
with a newly licensed nurse. For which of the following clients should the
nurse obtain informed consent from a guardian?
A 15-year-old client who requires an open reduction of a fracture.
MY ANSWER
The nurse should have the parent or guardian sign an informed consent prior
to a surgical procedure for a minor. The universal consent for treatment
does not cover surgical or invasive diagnostic procedures.
A 6-month-old infant requiring IV antibiotics.
The nurse should not have the parent or guardian sign an informed consent
prior to administration of IV antibiotics to a 6-month-old infant, as the
universal consent form covers medication administration.
14-year-old client seeking prenatal care.
The nurse should not have the parent or guardian sign an informed consent
prior to referring a 14-year-old client for prenatal care. An adolescent
can legally give consent to healthcare needs related to contraception and
pregnancy needs as well as treatment for sexually transmitted infections.
A 5-year-old child requiring a chest x-ray.
The nurse should not have the parent or guardian sign an informed consent
prior to completion of a chest x-ray for a 5-year-old child, as the
universal consent form covers noninvasive diagnostic tests.
29. A nurse on a pediatric unit is admitting a 5-year-old child who has a
submersion injury and is awake and alert. The parent asks the nurse why the
child needs to stay in the facility. Which of the following responses
should the nurse make?
"Your child needs mechanical ventilation."
The nurse should not tell the parent the child needs mechanical
ventilation, as the child is awake and alert. A child who is not breathing
on their own or is experiencing respiratory distress requires mechanical
ventilation.
"We need to observe your child for cerebral swelling."
MY ANSWER
The nurse should inform the parents that the child needs observation
because they still are at risk for a complication from the submersion
injury. Complications can include respiratory compromise and cerebral edema
during the first 24 hr after the submersion.
"Your child needs to have an electroencephalogram."
The nurse should not tell the parent that the child needs an
electroencephalogram. This test is performed for a child who has seizures
or to determine brain death in an unconscious child.
"We need to perform an echocardiogram on your child."
The nurse should not tell the parent the child needs to stay in the
facility for an echocardiogram, which is a noninvasive measure of the
electrical activity of the heart.
30.
A nurse is caring for an infant who has pyloric stenosis and a new
prescription for 0.9% sodium chloride with 10 mEq of potassium chloride.
The infant is lethargic and has a potassium level of 3.5 mEq/L. Which of
the following actions should the nurse take?
Implement seizure precautions.
The nurse should identify this potassium level as below the expected
reference range of 4.1 to 5.3 mEq/L for infants. The nurse should monitor
for cardiac abnormalities for an infant who has a potassium level outside
the expected reference range. Lethargy, hyporeflexia, and fatigue are
additional manifestation of hypokalemia.
Offer the infant 15 mL of formula.
The nurse should insert an NG tube to maintain gastric decompression prior
to surgical correction of the stenosis. The nurse should keep the infant
NPO.
Check the infant's serum creatinine.
MY ANSWER
The nurse should check the infant's serum creatinine and BUN levels prior
to and during the administration of IV potassium to ensure renal function
is adequate and avoid the development of hyperkalemia should renal failure
occur. The nurse also should closely monitor intake and output to ensure
adequate urinary output prior to and during the administration of IV
potassium.
Administer sodium polystyrene.
The nurse should identify this potassium level as below the expected
reference range of 4.1 to 5.3 mEq/L for infants. Sodium polystyrene
stimulates the body to excrete potassium through the large intestine and
would worsen the infant's condition.
31.
A nurse is planning care for a school-age child who is experiencing a
vaso-occlusive crisis. Which of the following actions should the nurse take
first?
Provide instructions to parents regarding immunizations.
Immunizations are an important part of prevention of vaso-occlusive crisis.
Sickling of the cells can occur as a result of an infection or dehydration
resulting from illness. The nurse should emphasize the importance of
receiving routine childhood immunizations such as measles and pertussis
along with meningococcal, pneumococcal, and Hib vaccines to prevent
infection. However, another action is the priority.
Discuss the use of pain medication with the child.
The nurse should discuss the use of analgesics with the child to manage
pain associated with vaso-occlusive crisis. Controlling the child's pain is
important to promote comfort. However, another action is the priority.
Encourage the child to increase their fluid intake.
MY ANSWER
When using the airway, breathing, circulation approach to client care, the
first action the nurse should take is to promote hydration through the use
of oral and IV fluids. Hydration is important because it prevents further
sickling of the cells and delays the hypoxia-ischemia cycle.
Apply warm compresses to the child's joints.
Warm compresses applied to the affected joints promotes comfort and
prevents vasoconstriction, which could enhance sickling. The nurse should
apply warm compresses. However, another action is the nurse's priority.
32.
A nurse is reviewing the admission laboratory report of a school-age child
who has glomerulonephritis. Which of the following laboratory results
should the nurse expect to find?
BUN 32 mg/dL
The nurse should identify this finding as above the expected reference
range of 5 to 18 mg/dL for a child. A child who has glomerulonephritis will
have an elevated BUN because of the impaired glomerular filtration rate,
which results in retention of urea in the blood.
Absence of urine protein
MY ANSWER
The nurse should identify that the absence of urine protein as an expected
finding in a child who does not have glomerulonephritis. A child who has
glomerulonephritis will have proteinuria, which is an increase in urinary
protein due to impaired glomerular filtration.
Urine specific gravity 1.020
The nurse should identify this finding as within the expected reference
range of 1.016 to 1.022 for a child who has normal fluid intake. An
expected finding for a child who has glomerulonephritis would be an
increased urine specific gravity.
Potassium 3.3 mEq/L
The nurse should identify this potassium level as below the expected
reference range of 3.4 to 4.7 mEq/L for a child. A child who has
glomerulonephritis will have a potassium level that is either increased or
within the expected range.
33.
A nurse is assessing a child who has heart failure. Which of the following
clinical manifestations should the nurse expect?
Warm extremities
Heart failure involves an inability of the heart to pump effectively,
limiting perfusion to major organs and the extremities. The nurse should
expect a child who has heart failure to exhibit pale, cool extremities.
Frequent headaches
A child who has heart failure can exhibit neurologic manifestations, such
as increased restlessness or irritability as a result of hypoxia and
impaired cardiac function. However, frequent headaches are not an expected
manifestation associated with heart failure.
Distended neck veins
MY ANSWER
A child who has heart failure will exhibit manifestations of increased
blood volume, such as distended neck veins. This occurs because of the
secretion of the hormone ADH, which holds onto sodium and water in response
to decreased cardiac output and renal perfusion.
Weight loss
A child who has heart failure will exhibit weight gain as a result of
sodium and water retention. As the heart failure progresses, dependent and
periorbital edema, ascites, and pulmonary effusions result.
34. A nurse is providing discharge teaching to the parent of a 5-year-old
child who has leukemia and is receiving chemotherapy. Which of the
following statements by the parent indicates an understanding of the
teaching?
"I will take my son's rectal temperature daily."
The parent should not take the child's rectal temperature, as this can
cause trauma to the rectal mucosa. Injury to the rectal mucosa can lead to
bleeding or infection.
"I will make sure to inspect my son's mouth every day for sores."
MY ANSWER
A child who has leukemia and is receiving chemotherapy is at increased risk
for mucositis; Therefore, the parent should inspect the child's mouth daily
for lesions or ulcerations and report these to the provider. Open lesions
can easily become infected in the child who is immunocompromised.
"I will make sure my son gets his MMR vaccine this week."
A child who has leukemia and is receiving chemotherapy will have a
compromised immune system and should not receive live vaccines such as MMR.
Live vaccines, if administered to an individual who is immunocompromised,
can result in a vaccine-induced illness. This occurs when a vaccine causes
the illness it is meant to prevent.
"I will ensure my son exercises a little each day by riding his bicycle."
A child who has leukemia and is receiving chemotherapy is at risk for
thrombocytopenia. The child should avoid activities that can cause bleeding
or injury (riding bicycles, skateboarding, and contact sports).
35.
A nurse in an emergency department is caring for a child who is
experiencing an acute asthma attack. Which of the following findings is the
priority for the nurse to report to the provider?
Expiratory wheeze
MY ANSWER
An expiratory wheeze is an expected finding for a child who is experiencing
an asthma attack and should be reported to the provider to allow for
effective treatment. However, there is another finding that is the nurse's
priority to report to the provider.
Heart rate 100/min
A heart rate of 100/min is an expected finding for a child who is
experiencing an asthma attack and should be reported to the provider to
allow for effective treatment. However, there is another finding that is
the nurse's priority to report to the provider.
Profuse sweating
Profuse sweating indicates that this child is at risk for severe
respiratory distress as a result of status asthmaticus and requires
immediate intervention. This is the priority for the nurse to report to the
provider. Other manifestations that should be reported immediately include
nasal flaring, distended neck veins, and tachypnea. The nurse should remain
with the child to provide support and intervention if intubation becomes
necessary.
Oxygen saturation 94%
An oxygen saturation of 94% indicates the child is experiencing asthma
manifestations on a moderate level of severity. This finding should be
reported to the provider to allow for effective treatment; .However, there
is another finding that is the nurse's priority.
36.
A nurse is planning to obtain a rectal temperature from a toddler. Which of
the following actions should the nurse take?
Insert the tip of the thermometer 5 cm (2 in) into the rectum.
MY ANSWER
The nurse should insert the tip of the thermometer no more than 2.5 cm (1
in) into the child's rectum to prevent injury.
Place the child in prone position.
The nurse should place the child in a side-lying, supine, or prone position
to obtain a rectal temperature.
Stabilize the thermometer at the distal end.
The nurse should stabilize the thermometer close to the child's rectum to
prevent injury.
Direct the tip of the thermometer toward the spine during insertion.
The nurse should direct the tip of the probe toward the umbilicus during
insertion because this is the direction of the rectum. Pointing the tip of
the thermometer toward the spine can increase the risk of rectal
perforation.
37.
A nurse is planning a community education series for teachers of children
who have attention-deficit hyperactivity disorder (ADHD). Which of the
following classroom strategies should the nurse include in the teaching?
Accompany verbal instructions with visual references.
The nurse should instruct the teachers to use visual references along with
verbal instructions for children who have ADHD. Using both verbal and
written instruction provides clear communication of expectations for the
children.
Vary the classroom routine to keep the children interested.
The nurse should not instruct the teachers to vary their classroom routine
to maintain the interest of children who have ADHD. Children who have ADHD
require a consistent environment that is predictable to assist with focus
and the ability to complete expected tasks.
Limit presentation of subjects of interest to the children to the
afternoons.
The nurse should encourage the teachers to alternate topics of high
interest to the children with topics of less interest. This will help to
retain the attention of the children.
Increase classroom assignments to stimulate learning.
MY ANSWER
The nurse should not instruct the teachers to increase classroom
assignments for children who have ADHD. Teachers might need to decrease
classroom assignments to allow the children time to complete the work.
38.
A nurse is assessing a 4-year-old child who is 2 days postoperative
following insertion of a ventriculoperitoneal shunt. Which of the following
findings is the nurse's priority?
Urine output of 50 mL in 2 hr
The nurse should monitor urine output of the child because a low urine
output can be an indication of decreased renal perfusion, renal injury, or
dehydration. However, a urine output of 50 mL in 2 hr is nonurgent because
it is an expected finding for a 4-year-old child. There is another finding
that is the priority.
Lethargy
MY ANSWER
When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is lethargy. This can indicate a
decreased level of consciousness or increased intracranial pressure, both
of which requires immediate intervention. Lethargy is the priority finding.
Respiratory rate 24/min
The nurse should monitor the child's respiratory rate following a surgical
procedure. Increased respirations can be an indication of a postoperative
complication such as pneumonia. Decreased respirations can indicate over
sedation or a neurologic problem. However, a respiratory rate of 24/min is
nonurgent because it is an expected finding for a 4-year-old child. There
is another finding that is the priority.
Absent Babinski reflex
The nurse should perform neurological examinations of the child following
placement of a ventriculoperitoneal shunt to identify potential increases
in intracranial pressure. However, an absent Babinski reflex is nonurgent
because it is an expected finding for a 4-year-old child. There is another
finding that is the priority.
39.
A nurse is planning care for a child who is postoperative following a
below-the-knee amputation. Which of the following interventions should the
nurse include in the plan of care?
Elevate the child's residual limb for 48 hr.
The nurse should plan to elevate the child's residual limb for the first 24
hr following surgery. Elevating the leg longer than 24 hr can cause hip
contractures and lead to difficulties with future ambulation.
Apply a loose-fitting bandage onto the child's residual limb.
The nurse should plan to apply an elastic bandage in a figure-eight pattern
to apply pressure to the residual limb. A pressure dressing that controls
edema also decreases the likelihood of hemorrhage and assists in contouring
the residual limb for future prosthetic placement.
Perform active and isotonic range-of-motion exercises.
MY ANSWER
The nurse should plan to perform both active and isotonic range-of-motion
exercises of the joints above the amputation site several times per day.
This will maintain joint mobility, which is necessary for future
ambulation.
Clean the incision using half-strength hydrogen peroxide every 8 hr.
The nurse should not plan to clean the incision with half-strength hydrogen
peroxide, as this can irritate the tissue. The nurse should clean the
incision with soap and water each day while assessing the limb for
manifestations of infection or skin breakdown.
40.
A nurse in an emergency department is caring for a child who has ingested
kerosene. The child is lethargic, grunting, and gagging. Which of the
following actions should the nurse take?
Initiate chelation therapy.
The nurse should not initiate chelation therapy for a child who has
ingested kerosene. Chelation therapy removes iron from circulating blood
and is not useful for the treatment of hydrocarbon ingestion.
Prepare for intubation with a cuffed endotracheal tube.
The nurse should anticipate that the child will require intubation with a
cuffed endotracheal tube because of the high risk of aspiration. This child
is at risk for aspiration because they are lethargic, grunting, and
gagging.
Inject deferoxamine subcutaneously.
Deferoxamine is an antidote used in the treatment of iron toxicity. It is
not used in the treatment of hydrocarbon ingestion.
Administer activated charcoal.
MY ANSWER
The nurse should administer activated charcoal to treat a child who has
ingested excess aspirin.
FLAG
A nurse is creating a plan of care for a school-age child who is
postoperative following a tonsillectomy. Which of the following
interventions should the nurse include?
Instruct the child to gargle using salt water every 4 hr.
MY ANSWER
The nurse should identify that gargling is contraindicated in children who
are postoperative following a tonsillectomy. Gargling increases the risk
for bleeding and should be avoided.
Give the child fluids using a straw.
The nurse should avoid giving the child a straw to drink fluids from
because straws can damage the surgical site and cause bleeding.
Ask the child to take deep breaths and cough every 30 min.
Although the nurse should encourage deep breathing postoperatively to
prevent atelectasis, the child should avoid coughing, blowing their nose,
clearing their throat, or any activities that could cause bleeding.
Apply an ice collar to the child's neck.
The nurse should apply an ice collar to the child's neck to promote comfort
and minimize swelling. The nurse also should administer prescribed
analgesics to the child around the clock to minimize pain.
A nurse is teaching a female adolescent who reports frequent urinary tract
infections. Which of the following instructions should the nurse include in
the teaching?
Wipe from back to front after voiding.
The nurse should instruct the adolescent to wipe from front to back after
voiding to prevent the transfer of micro-organisms from the rectal area to
the urethra.
Wear nylon underwear.
The nurse should instruct the adolescent to wear cotton underwear to
minimize perineal irritation. Cotton also allows air to flow to the
urethral meatus, limiting the growth of bacteria.
Void at least every 3 to 4 hr.
MY ANSWER
The nurse should instruct the adolescent to urinate as soon as they feel
the urge and to avoid waiting to void. Urinary stasis increases the risk
for infection.
Reduce dietary intake of fiber.
The nurse should not instruct the adolescent to reduce their intake of
fiber. The adolescent should increase their intake of fiber and fluids to
prevent constipation, which can increase the risk for urinary tract
infection.
43.A nurse is teaching about injury prevention to the parent of a toddler.
Which of the following safety measures should the nurse include in the
teaching?
Place a throw rug under the crib.
The nurse should instruct the parent to place a throw rug under the crib
because the toddler can fall out of the crib. The nurse should also
instruct the parent to move the toddler to a youth bed when they are able
to climb out of the crib.
Select a toy box with a lid that locks in the closed position.
MY ANSWER
The nurse should instruct the parent to select a toy box without a lid or
with a lid that locks securely in the open position. A toy box with a lid
that locks in the closed position places the toddler at risk for injury or
suffocation if entrapment occurs.
Offer popcorn as a snack food.
The nurse should instruct the parent not to offer popcorn as a snack food,
because they are a choking hazard. If the toddler does not chew the popcorn
completely, it can occlude their airway.
Set the water heater temperature to 54.4° C (130° F).
The nurse should instruct the parent to set the temperature on the hot
water heater between 49° to 51.6° C (120° to 125° F) to prevent scalding of
the toddler.
44.
A nurse in an emergency department is assessing a 5-year-old child who has
a concussion. Which of the following manifestations should the nurse
identify as an early indication of increased intracranial pressure?
Nausea
The nurse should identify that nausea is an early finding of increased
intracranial pressure in a child.
Papilledema
The nurse should identify that papilledema is a late finding of increased
intracranial pressure in a child.
Dilated pupils
The nurse should identify that dilated pupils along with a decreased
pupillary response are late findings of increased intracranial pressure in
a child.
Bradycardia
MY ANSWER
The nurse should identify that bradycardia is a late finding of increased
intracranial pressure in a child.
FLAG
A nurse is preparing to obtain a blood sample for an Hgb from a child who
has hemophilia. Which of the following actions should the nurse plan to
take?
Apply a transparent dressing to the site after the venipuncture.
MY ANSWER
The nurse should hold pressure or place a pressure dressing on the
venipuncture site after obtaining the blood sample. The removal of a
transparent dressing can cause increased trauma to a child who has
hemophilia.
Apply a cold compress to the site prior to obtaining the sample.
The nurse should not apply a cold compress to the extremity prior to
obtaining the blood sample, because this will cause vasoconstriction,
making it more difficult to obtain the blood sample. The use of a lidocaine
or prilocaine cream provides topical anesthetic and can be used to minimize
the discomfort of the procedure.
Perform an Allen test prior to obtaining the blood sample.
An Allen test is a procedure used to assess arterial circulation prior to
obtaining arterial blood samples. An Hgb requires venous blood sampling.
Obtain the sample using venipuncture.
The nurse should obtain the blood sample by venipuncture because this
method allows for less bleeding than a finger puncture.
47.
A nurse is caring for a child who has terminal leukemia. The parents ask
the nurse, "When will we know that our child is nearing the end of their
life?" Which of the following statements should the nurse make?
"Your child's skin will appear flushed."
The nurse should inform the parents that their child will have pale skin
near the end of their life. The skin is cool to the touch and might appear
grayish-blue as death nears. Mottling might occur in the extremities and
move toward the body core because of a decrease in cardiac output and
perfusion to the extremities.
"Your child will lose movement in their legs."
MY ANSWER
The nurse should inform the parents that their child will lose movement of
the lower extremities. This progressive loss of movement will move up the
body as death nears.
"Your child will first lose the ability to hear."
The nurse should inform the parents that the sense of hearing is the last
sense to fail as death nears. Loss of sensation develops before hearing
loss, and the child might become more sensitive to light.
"Your child's blood pressure will start to increase."
The nurse should inform the parents that their child will experience
decreased cardiac output, leading to a drop in blood pressure and decreased
pulses.
48.
A nurse is planning care for an adolescent client who has sickle cell
anemia and is experiencing a vaso-occlusive crisis. Which of the following
interventions is the nurse's priority?
Applying heat to the affected areas
MY ANSWER
The nurse should apply heat to the affected areas to increase circulation
and decrease pain. However, another action is the priority.
Administering prophylactic antibiotics
The nurse should administer prophylactic antibiotics to prevent bacterial
infection because the adolescent's body has a decreased ability to fight
infection. However, another action is the priority.
Administering the pneumococcal vaccine
The nurse should administer the pneumococcal vaccine to reduce the risk of
infection, which can exacerbate vaso-occlusive crisis. However, another
action is the priority.
Promoting bed rest
The first action the nurse should take when using the airway, breathing,
circulation approach to client care is to increase tissue oxygenation. An
adolescent who has sickle cell anemia and is experiencing a vaso-occlusive
crisis has a higher requirement for cellular oxygenation. Therefore, the
nurse should reduce the client's metabolic demands for oxygen and limit
cardiac oxygen consumption by encouraging rest.
FLAG
A nurse is teaching an adolescent how to use a peak expiratory flow meter
(PEFM). The nurse should identify that which of the following statements by
the child indicates an understanding of the teaching?
"I will breathe in through the mouthpiece, hold my breath for 5 seconds,
and then exhale."
Breathing in through the mouthpiece and holding the breath for 5 seconds is
an incorrect method of using the PEFM. The correct method of using the PEFM
is to forcefully exhale for 1 second as quickly as possible to measure the
amount of air exhaled.
"If I get a reading in the green zone, I will tell my parents right away so
they can call the doctor."
Values in the green zone represent 80% to 100% of the child's personal
best. This indicates that asthma is under good control and does not warrant
calling the provider.
"I will slowly exhale through the mouthpiece over a 10-second interval."
Slowly exhaling through the mouthpiece over a 10-second interval is an
incorrect method of using the PEFM. The correct method of using the PEFM is
to forcefully exhale for 1 second as quickly as possible to measure the
amount of air exhaled.
"I will record the highest reading of the three attempts."
MY ANSWER
The child should forcefully exhale for 1 second as quickly as possible to
measure the amount of air exhaled and repeat this process three times. The
child should wait 30 seconds between attempts and record the highest of the
three readings.
FLAG
A nurse is assessing a 2-year-old child following a surgical procedure.
Which of the following pain tools should the nurse use?
Face, Legs, Activity, Cry, Consolability (FLACC) scale
MY ANSWER
The nurse should use the FLACC scale to assess the toddler's pain level.
The FLACC scale is used for infants and children from 2 months to 7 years.
Oucher scale
The nurse should not use the Oucher scale to assess pain in a toddler. The
Oucher scale is used for children aged 3-13 years. and requires the child
to point to each section on the scale to describe variations in pain
intensity or to point to a picture and describe variations in pain.
FACES scale
The nurse should not use the FACES pain rating scale to assess pain in a
toddler. The FACES scale is used for children aged 3 years and older and
requires the child to identify pain by pointing to a face that represents
the level of pain the child is experiencing.
Visual Analog Scale (VAS)
The nurse should not use the VAS pain scale to assess pain in a toddler.
The VAS scale is used for children older than 4.5 years old and requires
the child to understand the concept of less pain to more pain and the
ability to make a written mark on a pain scale that represents the level of
pain the child is experiencing.
FLAG
A nurse is providing nutritional teaching to the parents of a child who has
acute glomerulonephritis with pitting edema. Which of the following foods
should the nurse recommend be eliminated from the child's diet?
Hot dogs
MY ANSWER
Acute glomerulonephritis is a renal disorder resulting in edema,
hypertension, hematuria, and proteinuria. If required, dietary changes
require limitation of foods that are high in sodium because of the edema
and hypertension. The nurse should recommend the elimination of hot dogs,
or other processed meats that are high in sodium, from the child's diet.
Canned mixed fruit
The nurse should identify that canned mixed fruit is very low in sodium and
is permissible for a child who has acute glomerulonephritis.
Steamed green beans
The nurse should identify that steamed green beans are very low in sodium
and are permissible for a child who has acute glomerulonephritis. Beans are
also an excellent source of complex carbohydrates, which are recommended
for this client.
Whole wheat macaroni
The nurse should identify that whole wheat macaroni is very low in sodium
and is permissible for a child who has acute glomerulonephritis. In
addition, whole wheat macaroni is an excellent source of complex
carbohydrates, which are recommended for this child.
FLAG
A nurse is providing teaching about home safety to the parents of an
infant. Which of the following statements should the nurse make?
"Use a hot-mist vaporizer to manage congestion."
The nurse should instruct the parents to use a cool-mist vaporizer to avoid
the risk of burns. Additionally, the nurse should instruct the parents to
ensure the infant cannot reach the vaporizer to avoid injury.
"Place your infant on a firm mattress for sleeping."
MY ANSWER
The nurse should instruct the parents to place the infant in a supine
position on a firm mattress for sleeping. This decreases the risk for
suffocation.
"Set your water heater temperature to 130 degrees Fahrenheit."
The nurse should instruct the parents to set the water heater temperature
to 49° C (120° F) to reduce the risk for burns to the infant.
"Begin using a wheeled walker when your infant is 9 months old.”
The nurse should instruct the parents to use a stationary walker, instead
of one with wheels, to avoid the risk for falls and injury to the infant.
FLAG
A nurse in a pediatric clinic is providing teaching to the parent of an
infant who has gastroesophageal reflux (GER). The nurse should identify
that which of the following statements by the parent indicates an
understanding of the teaching?
"I will give lansoprazole 30 minutes after her feeding."
The mother should give lansoprazole to her infant 30 min before feeding.
Administering lansoprazole, a proton pump inhibitor, 30 min prior to meals
ensures the peak plasma concentration of the medication occurs during
mealtimes. This medication reduces gastric hydrochloric acid secretion and
can stimulate an increase in lower esophageal sphincter tone, which can
prevent reflux of stomach contents into the esophagus.
"I will lay my baby on her side after feedings."
MY ANSWER
The parent should not lay their infant down following a feeding, as this
position will worsen gastroesophageal reflux. The parent should place the
infant upright in an infant seat or raise the head of the bed 30° for 1 hr
following feedings.
"I will add rice cereal to my baby's feedings."
The mother can add rice cereal to formula or expressed breast milk to
thicken the feedings. Thickened feedings can decrease the number of
vomiting episodes the infant experiences.
"I will use a nipple that has a wide base to feed her."
The parent should create a larger hole within the nipple to help the infant
suck more easily. A wide-based nipple is used for feeding infants who have
a cleft lip.
FLAG
A nurse is providing pre-procedure teaching to the parents of a preschooler
who has nephrotic syndrome and is scheduled for a percutaneous renal
biopsy. Which of the following statements should the nurse include?
"Your child can eat and drink up to 2 hours prior to the test."
In the event that bleeding or accidental perforation of an abdominal organ
occurs, the child will need to be taken to surgery. The NPO status will
decrease the risk of aspiration if surgery is necessary.
"Your child will need to be on bed rest for 6 hours following the test."
The nurse should instruct the parents that the child will need to be on bed
rest for 24 hr following the test. The activity restriction is necessary to
prevent bleeding following the procedure.
"Your child will have a pressure dressing on the biopsy site following the
test."
MY ANSWER
The nurse should instruct the parents that the child will have a pressure
dressing on the site of the biopsy following the test to minimize bleeding.
The nurse also might use a sandbag to maintain pressure to the puncture
site.
"Your child will receive contrast dye via an IV during the test."
The nurse should instruct the parents that the child may receive oral
pre-procedure medication for sedation for a renal biopsy. However, contrast
dye is not used for this diagnostic test.
FLAG
A nurse is caring for a toddler who is experiencing hyperglycemia. Which of
the following manifestations should the nurse expect?
Shallow respirations
The nurse should not expect the toddler to have shallow respirations, as
this is a manifestation of hypoglycemia. A toddler who is experiencing
hyperglycemia exhibits deep, rapid (Kussmaul) respirations.
Moist mucous membranes
The nurse should not expect the toddler to have moist mucous membranes. A
toddler who is experiencing hyperglycemia exhibits dry mucous membranes.
Skin pallor
The nurse should not expect the toddler to have skin pallor, as this is a
manifestation of hypoglycemia. A toddler who is experiencing hyperglycemia
exhibits flushed skin and might have signs of dehydration.
Lethargic mood
MY ANSWER
The nurse should expect the toddler to be lethargic. A toddler who is
experiencing hypoglycemia will be irritable and have a labile mood.
FLAG
A nurse is providing discharge teaching to the parent of a school-age child
who has juvenile idiopathic arthritis (JIA). The nurse should identify that
which of the following responses by the parent indicates an understanding
of the teaching?
"I will ensure that my child takes a 1 hour nap each day."
A child who has JIA should be discouraged from sleeping during the day
because it can cause joint stiffness and interfere with nighttime sleep.
The child should instead rest daily with activities such as reading,
watching television, and listening to music.
"I will give my child prednisone as needed for pain."
Prednisone is a glucocorticoid that acts as an anti-inflammatory agent and
is given on a scheduled basis during exacerbations.
"I will apply cool compresses to my child's painful joints during
exacerbations."
MY ANSWER
The parent should apply moist heat, rather than cool compresses, to relieve
pain and stiffness in affected joints. Having the child soak in a bathtub
of warm water is an effective strategy for relieving pain and stiffness in
multiple joints.
"I will have my child wear splints during the night."
The parent should have the child wear splints during the night to prevent
joint deformities and reduce and minimize pain from inactivity.
FLAG
A nurse is caring for a 6-month-old infant who has acute vomiting and
diarrhea. Which of the following manifestations should the nurse identify
as an indication of moderate dehydration?
Capillary refill greater than 4 seconds
The nurse should identify that a capillary refill time of greater than 4
seconds indicates severe dehydration. An infant experiencing moderate
dehydration will exhibit a capillary refill time of 2 to 4 seconds.
Bradycardia
The nurse should identify that bradycardia is not a manifestation of
dehydration. An infant experiencing dehydration will exhibit a heart rate
that is either within or above the expected range, depending upon the
severity of fluid loss.
Tachypnea
The nurse should identify that tachypnea is a manifestation of moderate
dehydration. As dehydration worsens, breathing becomes hyperpneic.
Lethargy
MY ANSWER
The nurse should identify that an infant who is lethargic has severe
dehydration. An infant experiencing moderate dehydration will exhibit
increased irritability.
A nurse is providing teaching about food choices to the parent of a
school-age child who has celiac disease. Which of the following statements
by the parent indicates an understanding of the teaching?
"I can offer popcorn as a snack food."
MY ANSWER
A child who has celiac disease has an inability to digest glutens found in
grains, such as wheat, barley, rye and oats. Corn is an acceptable
substitute grain and is gluten-free. Therefore, popcorn is an appropriate
food for the parent to offer the child as a snack.
"I will make sandwiches on rye bread."
Gluten is present in many baked goods, such as rye bread. Consumption of
grains containing gluten can result in steatorrhea, abdominal distention,
and failure to thrive including nutrient deficiencies. The nurse should
instruct the parent not to make sandwiches with rye bread because rye
contains gluten.
"I will purchase graham crackers to pack in their lunchbox."
The nurse should instruct the parent not to pack graham crackers in the
child's lunchbox, because graham crackers contain wheat flour. Therefore,
they are not gluten-free.
"I can make beef barley soup for dinner."
The nurse should instruct the parent not to make beef barley soup for
dinner because barley contains gluten.
A nurse is caring for an infant who has returned to the pediatric unit
following surgical repair of a cleft lip. Which of the following actions
should the nurse take?
Monitor temporal artery temperature.
The nurse should check the infant's temperature by scanning the temporal
artery to monitor for manifestations of infection. Other manifestations of
infection the nurse should monitor for include: redness, warmth, and
drainage from the incision site.
Restrain the infant's wrists.
MY ANSWER
The nurse should place elbow restraints on the infant to prevent disruption
of the suture line.
Place the infant in a prone position.
The nurse should position the infant in an upright or lateral position to
facilitate drainage of secretions and prevent aspiration. The infant could
disrupt the suture line if placed in a prone position.
Gently clean the suture line with povidone-iodine solution.
The nurse should gently clean the suture line on the lip with sterile
saline or sterile water after each feeding and as needed.
A nurse is providing nutritional teaching to the parents of a 2-year-old
child. Which of the following statements by the parent indicates an
understanding of the teaching?
"My child should have 4 ounces of protein per day."
A toddler who is 2 years old should consume 2 oz of protein daily. The
nurse should instruct the parents to follow recommendations for dietary
guidelines from the Dietary Guidelines for Americans (2015-2020) to achieve
adequate caloric and nutrient needs.
"I should feed my child 1 cup of vegetables per day."
MY ANSWER
A toddler who is 2 years old should have 1 cup (8 oz) of vegetables per
day. A variety of vegetables should be introduced to the toddler. The nurse
should instruct the parents to follow recommendations for dietary
guidelines from the Dietary Guidelines for Americans (2015-2020) to achieve
adequate caloric and nutrient needs.
"I should give my child 6 cups of milk a day."
A toddler who is 2 years old should have no more than 24 to 30 oz of milk
per day to prevent iron deficiency anemia. This occurs in the toddler who
consumes large amounts of dairy and then fails to consume adequate amounts
of iron-containing proteins. To enhance growth of the toddler's brain and
body, whole milk products are recommended instead of low-fat or fat-free
varieties.
"My child should consume 800 calories per day."
A toddler who is 2 years old should consume approximately 1,000 to 1,400
calories daily, divided into three meals and two or three snacks. The nurse
should instruct the parents to follow recommendations for dietary
guidelines from the Dietary Guidelines for Americans (2015-2020) in order
to achieve adequate caloric and nutrient needs.
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