*NURSING > HESI > HESI PEDIATRICS REVIEW PRACTICE Questions and Answers (GRADED A+) with well explained RATIONALES | 1 (All)


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HESI PEDIATRICS REVIEW PRACTICE QUESTIONS. 1. When caring for a child with congenital heart disease and polycythemia, which nursing action has the highest priority? A. Administering oxygen therapy... continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin levels Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted. 2. The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley. 3. A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse? A. “My son often chokes while I am feeding him.” B. “Is it normal for my child’s legs to cross each other?” C. “He gets stiff when I pull him up to a sitting position.” D. “My 4-year-old son is jealous of his little brother.” Rationale: Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. Option D is an expected behavior and may need to be addressed, but it is not a priority over choking. 4. A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? (Select all that apply.) A. Bone pain B. Tremors C. Nystagmus D. Abdominal distention E. Pallor Rationale: Options A and E list the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia. 5. The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces. B. Administer magnesium sulfate. C. Place the child on a clear liquid diet. D. Assess the stool for white color. Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally removes any remaining barium. 6. The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child’s head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths. Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child’s condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension. 7. The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime Rationale: Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal. 8. Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites Rationale: Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics. 9. A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which action should the nurse take first? A. Obtain a scale to weigh the infant’s diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis. Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse’s priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed. 10. The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor. What is the most important safety precaution for child? A. Maintain NPO status. B. Limit visitors to the immediate family. C. Place a do not palpate abdomen sign on head of bed. D. Encourage ambulation in the pre-operative period. Rationale: Protect child from injury; place a sign on bed stating “no abdominal palpation” (to prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time. 11. The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. “Our first child was born with a cleft lip.” B. “We are very careful not to get sunburns in our family.” C. “My first child sometimes got a diaper rash.” D. “My husband and our daughter are both lactose-intolerant.” Rationale: Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child’s outbreaks. Option A is not a contributing factor. Option B is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. Option C is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs. 12. A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What is the nurse’s best instruction to the mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough. Rationale: The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition. 13. The nurse is assessing a male adolescent client’s knowledge of contraception. The teen states, “I have all the info I need.” What is the best response by the nurse? A. “Tell me what you know about birth control.” B. “Do you know how to apply a condom?” C. “Teen pregnancy should not be taken lightly.” D. “You need to visit with your guidance counselor.” Rationale: Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A. Option B is narrow in focus. Options C and D are blocks to any further communication. 14. The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that mobility is greatly reduced. What is the most likely cause of the child’s impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA. 15. A father of a 5-year-old calls the nurse to report that his child, who has had an upper respiratory infection, is complaining of a headache, with a rectal temperature of 103°F/39.4°C. Which action has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child’s fluid intake. D. Tell the parent to take the child to the emergency department. Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation. Options A, B, and C are all valuable interventions after the client is assessed and diagnosed. 16. A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class. Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child’s home. 17. An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What action should the nurse take first? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat. Rationale: Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client’s digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin. 18. The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which action is most important for the nurse to take first? A. Assess the child’s mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child’s food likes and dislikes. D. Ask the parents about the child’s recent dietary intake. Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D. 19. When inserting a nasogastric tube into the stomach of a 3-month-old infant, which action is most important for the nurse to take first? A. Use a blanket as a mummy restraint. B. Monitor the infant’s heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents. Rationale: All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant’s heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B. 20. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences. Rationale: All these are important measures to review with the UAP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client comfort and reduce anxiety but are of a lower priority than option A. 21. The nurse is helping a family prepare to send their 7-year-old child to school for the first time. The child is wheel-chair bound, and has a permanent tracheostomy. What information must the nurse include in the teaching plan for the child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting. Rationale: Suctioning supplies should always be readily available for use with any client who has a tracheostomy. Options A, B, and C do not describe safe practices for this child with a tracheostomy. 22. A woman is being discharged following the birth of her second child. Her first child died at 6 weeks of age because of sudden infant death syndrome (SIDS). The mother tells the nurse that she is fearful that this infant will also develop SIDS. What is the nurse’s best response? A. “You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully.” B. “The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?” C. “An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need.” D. “My neighbor’s baby died of SIDS last year and she went to a SIDS support group. That really helped her.” Rationale: The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her. 23. What information about skincare will the nurse include in the teaching plan for parent of a 3-month old with eczema? (Select all that apply.) A. Bath water should be tepid and use only a mild soap when needed. B. Apply a thick layer of corticosteroids to the affected areas 5 times a day. C. Apply a cool, wet washcloth to the affected area for 5 minutes at a time. D. Do not use fabric softener when washing any of your child’s clothes. E. Keep your baby’s nails short, and cover hands with cotton socks if needed. Rationale: Corticosteroids should be applied in a thin layer and rubbed into the affected area. The remaining instructions are appropriate for a child with eczema. 24. A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child’s right hip during a routine physical examination. Which risk factor is most closely related to developmental hip dysplasia? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child Rationale: Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position, not the vertex (head-first) position. Twice as many females as males present in the breech position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus and compaction of the surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman. 25. The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature. Rationale: The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis. 26. Which preoperative nursing action should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting. Rationale: Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An antidiarrheal agent is not indicated. Option C is dangerous because of the potential for aspiration with frequent vomiting. 27. The nurse expects a 2-year-old child to exhibit which behavior? A. Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes. Rationale: Two-year-old children are egocentric and unable to share with other children. Options A, B, and D are behaviors of a preschooler. 28. The nurse is preparing a health teaching program for parents of toddlers and preschoolers, and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals. Rationale: The only reliable way to prevent poisonings in young children is to make the items inaccessible. Teaching children not to taste anything but food is important but ineffective for young children. Options C and D will not control a child’s curiosity. 29. The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys. B. Plays by himself for most of the day. C. Boasts aggressively when telling a story. D. Cries and is fearful when separated from his parents. Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler’s play is usually cooperative, so playing alone is not typical. 30. A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 99.6°F. How many calories per day will the nurse include in the infant’s plan of care? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day Rationale: An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1°F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect. 31. The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child’s crying during the recovery period? A. Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line. Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child with a cleft lip repair. 32. A 6-month-old infant is admitted to the postanesthesia care unit with elbow restraints in place. An endotracheal tube is in place connected to a ventilator, but the child will be extubated soon following recovery from anesthesia. Which action should the nurse include in the child’s postoperative care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours. Rationale: Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record. 33. A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child’s body are proportionally larger than an adult’s body? (Select all that apply.) A. Head B. Arms C. Legs D. Back E. Neck F. Chest Rationale: The standard rule of nines is inaccurate for determining burned body surface areas with children because a child’s head and neck are proportionately larger than an adult’s. Specially designed charts are commonly used to measure the percentage of burn in children. Options B, C, D, and F are not proportionately different. 34. A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding. Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child’s level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse’s report. Based on the laboratory finding, options B, C, and D are not indicated. 35. Following the administration of immunizations to a 6-month-old infant, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A. “I will give my baby a baby aspirin every 4 hours as needed for fever.” B. “I will call the clinic if my baby’s cry becomes high-pitched or unusual.” C. “I know I can expect my baby to be irritable over the next 2 days.” D. “I will exercise my baby’s legs regularly to decrease the soreness.” Rationale: Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye syndrome. Option B indicates a severe reaction, whereas option C is a common side effect. Option D decreases soreness in the thigh injection site. 36. During routine screening at a school clinic, an otoscope examination of a child’s ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day. Rationale: More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately. Based on the data obtained from the otoscope examination, options A, C, and D are not indicated. 37. A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly. Options B, C, and D are not recognized as common complications of trisomy 21. 38. At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent. 39. A newborn whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom will the child most likely exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection. Options A, B, and D are symptoms of AIDS complications that may occur later as the disease progresses. 40. An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which action will the nurse include when teaching the parents about immediate post-procedure care? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child’s lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site. Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site. Options A and D increase the risk for complications and are contraindicated. Option C is not necessary. Only the extremity that was catheterized requires immobilization. 41. Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose? 15 Rationale: 2.2 lb/1 kg = 22 lb/x kg x = 10 kg 1 kg/75 mg = 10 kg/x mg x = 750 mg 250 mg/5 mL = 750 mg/x mL x = 15 mL 42. The nurse notes that a 16-year-old is refusing classmates visits. Further assessment reveals a concern over edematous facial features. Which concern will the nurse plan to address first? A. Social isolation B. Altered health maintenance C. Knowledge deficit D. Ineffective coping Rationale: Peer acceptance and body image are significant issues in the growth and development of adolescents. Option A addresses the problem of a lack of contact with peers stemming from his desire to protect his ego. Options B, C, and D are not supported by the assessment finding. 43. A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which action should the nurse take first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments. Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client. Option A is not sufficient to prevent exposure to others. Option B must be done prior to exposure. 44. A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative Rationale: Children 4 to 5 years of age are in the “Initiative vs. Guilt” stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. “Autonomy vs. Shame and Doubt” occurs at 1 to 3 years of age. “Industry vs. Inferiority” occurs at 6 to 11 years; “Trust vs. Mistrust” occurs from birth to 1 year of age. 45. In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses Rationale: Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn. 46. A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which action should the nurse take to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line. Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water- soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring. 47. Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation Rationale: The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. Options A and D may cause the hernia to protrude but do not necessitate notification of the health care provider. Option C may not be specific to the hernia. 48. Which actions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent toileting routine. Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis. 49. Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion Rationale: Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis. 50. Which nursing interventions are therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child’s home. Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home. 51. Which vital sign is most important to assess in the 6-year-old child brought to the clinic with reddened, open, and oozing skin lesions? A. Pulse B. Temperature C. Respirations D. Blood pressure Rationale: Temperature is a sign of infection. Alterations in skin integrity can lead to infection which is most concerning with a child with open and oozing lesions. The remaining vital signs may change with infection, but temperature is the closest sign indicative of infection. 52. The mother of a 1-year-old states to the nurse, “Look at those red raised areas all over my baby! What could they be?” What is the next nursing action? A. Ask, “Has the baby been around anyone with scabies?” B. Check the infant’s record for the measles, mumps, and rubella immunization. C. State, “It looks like impetigo to me. It happens a lot in July and August.” D. Apply this Burow’s solution to the raised reddened areas. Rationale: Scabies is a skin condition caused by Sarcoptes scabiei which borrow under the skin. The condition is highly contagious. A scabicide is applied to kill the mites. All clothes, linens, and toweling used in the past 2 days by the infected person must be washed. This is not the presentation of the measles, mumps, or rubella. Impetigo presents as vesicles or pustules that turn into crusty in appearance. Burow’s solution is used for impetigo. 53. The nurse is providing care for a child newly admitted in a sickle cell crisis. In reviewing the admission prescriptions, which prescription is concerning and the nurse needs to confirm with the health care provider? A. Meperidine 15 mg IV every 4 hours, around the clock for pain. B. Hydrate with 2000 mL of oral fluids over the next 6 hours. C. Place cold compresses to affected joints for 15 minutes every 4 hours. D. Raise the head of the bed 20 to 30 degrees and dim the lights. Rationale: Meperidine (Demerol) can have severe neurologic effects in clients with sickle cell disease. Start with other analgesics such as morphine or hydromorphone. IV is the preferred route for these clients as they require round-the- clock treatment. Hydration is important to decrease the viscosity of the blood. Cool compresses can help alleviate some of the joint pain. The goal of positioning is to reduce strain on the joints. 54. Which foods will the nurse include in the meal plan for iron deficiency anemia? (Select all that apply.) A. Dried fruits B. Nuts C. Cheese D. Spinach salad E. Cod F. Red meat Rationale: Cheese and cod fish are not high sources. The remaining selections are iron-rich food selections along with egg yolks, kidney beans, legumes, liver, prune juice, seeds, shellfish, tofu, and whole grains. 55. A child is being sent home with a prescription for liquid iron. Which statements indicate to the nurse that the mother understands the discharge instructions? (Select all that apply.) A. “This medication will work in about a week.” B. “I will have my child drink this with a straw.” C. “Teeth brushing will follow the administration.” D. “I will watch for green, liquid stools.” E. “I will give this on an empty stomach.” Rationale: Iron supplements can take 4 to 6 weeks to start making a difference in the H/H. Stools may turn tarry/black with iron supplementation and constipation may occur. Drinking through a straw will help decrease the staining of the teeth as does brushing teeth after administration. Administering on an empty stomach helps increase absorption. 56. The nurse is administering a fluid resuscitation for a child admitted with burns to the legs and abdomen. What assessments are essential to determine if the resuscitation is successful? (Select all that apply.) A. Heart rate B. Urine output C. Appetite D. Rapid capillary filling E. Range of motion F. Alertness Rationale: Fluid shifts occur as a result of burn injuries. The vital assessments involve the cardiovascular (CV) and the neurological systems. Appetite involves the gastrointestinal system and range of motion involves the musculoskeletal system. The primary systems of focus are the CV, respiratory, and neurological. 57. The nurse is providing discharge instructions to the parents of a 9-year-old recently diagnosed with hemophilia. Which parent statement will the nurse need to correct? (Select all that apply.) A. “Swimming is a good activity for my child.” B. “My child can take part in the competitive dance team.” C. “I can enroll my child in a soccer camp for the summer.” D. “I will make sure my child wears a helmet, wrist and shin guards when riding a bike.” E. “I can allow my child to play with the children in the neighborhood when they play football.” Rationale: Children with hemophilia need to avoid sports that may result in bruising and internal bleeding. Non-contact sports such as swimming, dancing, and biking are encouraged to keep physically fit. Soccer and football are considered contact sports and should be avoided. 58. A child is recovering from a splenectomy secondary to a diagnosis of β-Thalassemia major. What is the most important instruction the nurse must include in the child’s discharge plan? A. Parental genetic counseling B. Include the pneumococcal vaccine. C. Weekly hemoglobin levels D. Report signs of infection. Rationale: The child is at risk for sepsis after a splenectomy. Report to the child’s health care provider any signs and symptoms of infection. Genetic counseling and the pneumococcal vaccine are important, but do not pose the risk of sepsis. Weekly hemoglobin levels are not necessary. 59. The in-patient nurse is caring for a child with leukemia. The parents are asking for help with meal selection for their child. What items will the nurse recommend? (Select all that apply.) A. Scrambled eggs B. Creamed corn C. Spaghetti and meatballs D. Macaroni and cheese E. Honey-based granola bars Rationale: Children with leukemia need food that is nutritious and requires little chewing. Meatballs and granola bars, though high in protein, are too difficult to chew. The remaining foods have both nutritive value and are easy to eat. 60. The nurse is reviewing a list of allowable immunizations which was developed by the parents of a child with leukemia. Which immunizations will the nurse to correct from the parents’ lists? (Select all that apply.) A. Measles B. Mumps C. Rubella D. Varicella E. Hepatitis B Rationale: The child must not receive any live virus vaccines. Hepatitis B is the only immunization from the list that is not a live virus. 61. The nurse is providing care to a child with a white blood cell count of 1.025 cell/mm³. What measures will the nurse take to decrease the risk for infection? (Select all that apply.) A. Assist with daily hygiene with an antimicrobial soap. B. Include fresh strawberries in the lunch menu. C. Replace the water in the pitcher every 4 hours. D. Encourage the addition of a green-leafy salad with supper. E. Offer a toothbrush and toothpaste after every meal and at bedtime. Rationale: Reduce environmental risks of infection by eliminating fresh fruits and vegetables. Use an antimicrobial soap with daily hygiene. Change water frequently to eliminate bacterial growth in standing water. Keep teeth clean by brushing after every meal and before bed. 62. The nurse is receiving report from the emergency department on an 8-month-old child scheduled for a craniotomy. Which assessments will the nurse include in the child’s care plan to evaluate for increased intracranial pressure? (Select all that apply.) A. Sunken fontanel B. Prominent sclera over the iris C. Listlessness D. Poor suck-swallow when feeding E. Increased head circumference Rationale: In addition to the correct answers, the child may have a bulging and tense fontanel, as well as irritability. The cranial sutures may be separated and the child may cry with minimal stimulation. 63. The nurse in the emergency department has recently admitted four children. Which child will the nurse bring to the attention of the health care provider first? A. A 2-year-old with vomiting and diarrhea for 48 hours B. A 4-year-old with a foreign body in the ear C. A 5-year-old with a temperature of 100°F/37.8°C D. A 7-year-old with green sputum and a respiratory rate of 20 Rationale: The child with vomiting and diarrhea is at risk for fluid volume deficit because he or she has more extracellular fluid. The foreign body in the ear does not pose any cardiovascular or respiratory compromise. Children can often tolerate higher temperatures. The green sputum may indicate a respiratory infection; however, the respiratory rate does not support respiratory compromise. 64. The nurse is planning care for a newborn. What is the best time to draw the newborn’s phenylketonuria (PKU)? A. Within 1 hour of birth B. Within 4 hours of birth C. Around 24 hours after birth D. Around 48 hours after birth. Rationale: Screening of newborns for PKU needs to occur after the baby has injected either formula or breast milk. If screening is conducted before 48 hours after birth, the screening should be repeated by 14 days after birth. 65. A child admitted to the emergency department is lethargic and has a fruity aroma to the breath, blurred vision, and a headache. What question will the nurse ask the parents first? A. “Has your child ever been treated for diabetes before this?” B. “Has your child been playing outside in the heat all day?” C. “Are any of your other children displaying these symptoms?” D. “Has your child been exposed to other sick children?” Rationale: The child is displaying signs of ketoacidosis. The fruity breath is a hallmark sign. Knowing if the child has had diabetes will help the health care team understand the underlying cause of the presenting symptoms and the best course of action. However, often DKA leads to the initial diagnosis of diabetes in children. 66. For the child admitted to the emergency department with an elevated blood glucose level, the nurse will anticipate an order for which kind of insulin? A. Levemir B. Regular C. NPH D. Lantus Rationale: Of the insulins listed, regular has the most rapid action. NPH is an intermediate acting insulin, and Lantus and Levemir are long acting insulins. 67. Which nursing action will the nurse take first for the child known to have diabetes admitted to the emergency room? A. Start an IV. B. Administer orange juice. C. Take a blood glucose reading. D. Dipstick urine for ketones. Rationale: Assessment of the blood glucose will determine the next course of action. Assessment first. Dipstick for ketones is an unreliable measure. Starting an IV and administering orange juice will depend on the blood glucose reading. 68. Which food items to treat hypoglycemia will the nurse include in the teaching plan for the child with insulin- dependent diabetes? A. Half cup of fruit juice B. Four sugar cubes C. One teaspoon of honey D. Three hard candies E. One small box of raisins Rationale: All of the selections noted have adequate glucose to treat hypoglycemia. 69. The nurse is teaching the sick day rules to the parents of child with insulin-dependent diabetes. Which instructions will the nurse include in the plan? (Select all that apply.) A. Restrict fluids to no more than 1000 mL/day. B. Encourage the child to eat a regular meal plan. C. Test for ketones in the urine with each void. D. Cut the insulin by 50% with each scheduled dose. E. Encourage rest and restful activities. Rationale: Fluids should not be restricted, offer more fluids to clear any ketones that may exist in the urine. The insulin regimen stays the same, unless otherwise prescribed by the HCP. There is no automatic reduction in the event of sickness. Notify the HCP with vomiting or signs of ketoacidosis. The remaining selections are correct for sick day rules. 70. A child presents to the emergency department with vomiting and diarrhea for 36 hours. Which finding is most concerning to the nurse? A. No tears when crying B. Urine specific gravity of 1.035 C. Pink lips and gums D. Temperature of 99.2°F/37.3°C Rationale: The normal specific gravity is 1.002 to 1.025. The high specific gravity is a sign that the child has a fluid volume deficit. No tears when crying is an indication of dehydration, but it is not as definitive as the specific gravity reading. Pink lips and gums are an expected finding. The temperature is a low-grade fever and not as concerning as the specific gravity. 71. The nurse in the emergency room is reviewing the prescriptions for a child admitted with diabetic ketoacidosis. Which prescriptions will the nurse question as they are concerning? (Select all that apply.) A. IV of 0.9% normal saline B. Regular insulin C. Clear liquid diet D. Glasgow coma scale assessment E. Restrict parents from visiting. Rationale: The child should be NPO until the condition stabilizes and the blood glucose readings approach the acceptable range. Parents can be a source of comfort and support. Increased anxiety can make the child’s condition worse. The remaining are acceptable treatments for DKA. 72. Upon initial assessment of a newborn, the nurse palpates the infant’s mouth and feels an incomplete closure of the soft palate. What other focused assessments will the nurse include in the newborns plan of care? (Select all that apply.) A. Suck B. Swallow C. Calorie intake D. Daily weight E. Moro reflex F. Plantar creases Rationale: The newborn has a cleft palate. The Moro, or startle, reflex is a neuromuscular evaluation. Plantar creases indicate maturity. The child with a cleft palate may not be able to coordinate a suck and swallow reflex. While newborns initially lose weight, daily weight and calorie counts are essential to assure intake for growth. 73. The nurse is performing discharge teaching to the parents after the birth of their child with a cleft palate. When planning for the timing of the cleft palate repair, what developmental milestones will the infant exhibit? (Select all that apply.) A. Sitting up with props B. Walks holding onto furniture C. Rolling over from front to back D. Knows familiar faces E. Finds hidden objects Rationale: Cleft palate repair generally occurs between 3 and 6 months. Walking holding onto furniture generally starts after 9 months and at 12 months, infants can find hidden objects. The remaining milestones are appropriate for 3 to 6 months. 74. The nurse assesses a newborn during an initial feeding of formula and notes choking, coughing, and bluish lips. What is the nurse’s next action? A. Stop the feeding. B. Firmly tap the newborn’s back. C. Look for blue hands and feet. D. Place the infant in a bassinette raised 30 degrees. Rationale: The infant is displaying signs esophageal atresia, the blue lips are the concerning sign in this scenario. The infant could aspirate the formula. The nurse must stop the feeding and further assess the infant. Firmly tap the back is appropriate for choking. Further assessment is not indicated as enough data are collected with the presenting signs. Further assessment may result in a delay of care. Raising the bassinette is an appropriate position, but not as important preventing aspiration. 75. A 6-month-old infant with poor weight gain and frequent emesis is diagnosed with gastroesophageal reflex. Which parent statements indicate the nurse’s teaching was effective. (Select all that apply.) A. “We will provide small and more frequent feedings.” B. “We will stop feeding every 2 to 3 minutes to burp the baby.” C. “Tummy position is best when placing our baby in the crib.” D. “We will tickle and play with the baby right after feedings.” E. “We will stop feeding if the baby starts to cough.” Rationale: Tummy position is only for limited time to decrease the sudden infant death syndrome, unless prescribed by a health care provider after the completion of a thorough risk assessment. Playing/tickling with the baby after eating can stimulate regurgitation. The baby needs to have quiet time after feeding. The remaining activities are appropriate for this child. 76. The clinic nurse is preparing a teaching plan for a child just diagnosed with lactose intolerance. What sources of calcium will the nurse include in the child’s plan? (Select all that apply.) A. Skim milk B. Sorbet C. Cheddar Cheese D. Yogurt E. Provolone cheese F. Cottage cheese Rationale: Skim milk contains an active lactose enzyme. If given to a client with lactose intolerance it needs to be accompanied by an enzyme replacement tablet. Sorbet is permissible for the client who is lactose intolerant, but it contains no calcium. The remaining selections contain calcium, but they contain inactive lactose. 77. The health care provider has prescribed a gluten-free diet for the child suspected of having Celiac disease. Which items will the nurse need to correct when the parents are reviewing the child’s dietary recommendations? (Select all that apply.) A. Ice cream purchased from the grocery store B. Hamburger with lettuce and onions C. Fried rice with chicken and peas D. Mixed green salad with strawberries E. Spaghetti with homemade sauce Rationale: A gluten-free diet contains protein sources from meat, chicken, fish, and pork. Also permissible are items that do not have grains from wheat, rye, and oats. Commercially prepared ice cream may contain items with gluten. Spaghetti contains wheat. The remaining items are gluten free. Remember, there is no bun listed on the hamburger selection. 78. A mother of a 4-year-old calls the clinic and reports that her child has non-regular, hard and dry stools. She reports a diet high in whole milk, processed meats, bananas, and macaroni and cheese. She states, “That’s all I can get my child to eat right now.” What is the nurse’s best reply? A. “Try replacing the macaroni with a whole wheat macaroni.” B. “Increasing the milk would be a good idea.” C. “She what happens when you take away the banana.” D. “Processed meats are not good for your child.” Rationale: The child’s diet needs to increase in fiber, replacing the macaroni will help increase the fiber in the child’s limited diet. This option works within the constraints of the child’s current limited diet. Decrease items containing milk and sugar. Bananas offer little fiber. Consider raw fruits with skins and/or seeds, such as blueberries or apples. Telling the mother that processed meats are not good for the child does not help increase the fiber in the child’s diet. 79. A mother is carrying in her 3-year-old to the emergency department (ED) screaming, “I think my baby swallowed a bottle of Tylenol.” What is the nurse’s next action? A. Notify the health care provider in the ED. B. Take the child’s vital signs. C. Start an IV. D. Ask the mother for the bottle containing the Tylenol. Rationale: Assessment first. Know the child’s baseline, unless the child is lifeless, then start CPR. Since there is no data indicating lifelessness and no option of CPR, then taking the vital sign assessment is correct. The health care provider will need to know the child’s condition to know how to proceed. An IV may be an unnecessary intervention, and only initiated when the child’s condition is known. Identifying the poison is important, but does not address the immediate needs of the child. 80. A nurse is conducting a community teach to a group of parents with toddlers. What information will the nurse include in the presentation? (Select all that apply.) A. Program the number for poison control in all cellphones. B. Keep medications in a locked cabinet. C. Place cleaning chemicals out of reach. D. Avoid strawberries and blueberries. E. Do not allow your children to pay with balloons. Rationale: This is a very active stage of life and toddlers will climb, jump, and play. Anything dangerous if ingested must be placed in a locked cabinet, such as cleaning chemicals. Placing these items high only poses a challenge for the adventuresome toddler. Balloons are an asphyxiation risk for this age group. An inhaled balloon or balloon fragment can lodge on the trachea. Poison control should be on the cell phone of all care providers. Small fruits are permissible, as long as they are administered in small quantities under supervision. They are an excellent source of fiber. 81. A mother calls into the clinic and reports her 4-year-old, who spends 50 hours in day care a week, is constantly scratching the perianal area. The child is also sleeping poorly and has started wetting the bed at night. What is the nurse’s next action? A. Bring the child to the clinic immediately. B. Take the child to the local hospital emergency department. C. Instruct the mother on how to perform the tape test. D. Have the mother place lanolin around the child’s anus. Rationale: Because the child is in day care (a crowded environment) for 50 hours a week, there is the potential for pinworm infection. The tape test will help determine (assessment) the presence of pinworms. Pinworms are not a medical emergency, so there is no need to have the child seen immediately. While lanolin may help the discomfort to the anal area, it does nothing to help with the cause of the itching. 82. A newborn is suspected of having an imperforate anus. What is most important for the nurse to include in the child’s plan of care? A. No rectal temperatures B. Take temperature every 2 hours. C. Report a temperature of 100°F/37.7°C. D. Show the mom how to take her child’s temperature. Rationale: An imperforate anus means that the anus did not form properly and there may be a membrane over the anal opening. No objects should be placed in the anal opening if this condition is suspected. There is no apparent infection in this case to increase the frequency of taking the newborn’s temperature. A temperature of 100°F/37.7°C is a low-grade fever and is not related to this condition. While it is important to show mom how to take a temperature, it is not as important as the potential trauma of a probe in an imperforate anus. 83. The school nurse assesses a high school age student with a reddened and edematous right eye, with clear discharge with purulent streaks. The student reports that the eye is itchy. What statements will the nurse include when assessing the student? (Select all that apply.) A. “Do you wear contact lenses?” B. “Stay here until I can contact a family member.” C. “Who have you been around in your classes today?” D. “You will need to be seen by a health care provider.” E. “How many family members do you have in your household?” F. “You must find out what you are allergic to as soon as possible.” Rationale: The child has classic symptoms of conjunctivitis, which is highly contagious. Conjunctivitis is not related to an allergy. The purulent streaks indicate there may be an infection and treatment by a health care provider is indicated. The family members and close contacts are at risk for contracting conjunctivitis. 84. The clinic nurse is reviewing the newly received lab reports. The report from an 8-year-old indicates chlamydial conjunctivitis. What is the nurse’s next action? A. Have the parents bring the child in for further examination. B. Alert the proper authorities of possible sexual abuse. C. Ask the health care provider to call in a prescription for the child. D. Assess the child’s chart to determine if immunizations are up-to-date. Rationale: Chlamydial conjunctivitis outside of the neonatal period is suspect of child abuse. Nurses are mandatory reporters and must report this finding. No further examination is needed with this laboratory finding. The health care provider can prescribe the appropriate treatment, which is the next step. Chlamydial conjunctivitis is not impacted my immunizations; the infection is spread by contact. 85. The nurse is preparing to administer eardrops to a 2-year-old. What is the proper procedure for administering this medication? A. Pull the pinna up and back. B. Pull the pinna down and back. C. Pull the pinna up and forward. D. Pull the pinna down and forward. Rationale: Up until a child is 3-year-old, the proper procedure for administering eardrops is by pulling the pinna down and back to straighten the ear canal. 86. The nurse is reviewing the discharge instructions of the parents of a 2-year-old who just underwent a myringotomy. What instructions will the nurse include in the parent’s teaching? (Select all that apply.) A. Do not immerse the child’s head in water when bathing. B. Administer the Tylenol as prescribed. C. Do not substitute aspirin for the prescribed Tylenol. D. Purchase earplugs and place them during bath time. E. Change the bandage on the ear three times a day. Rationale: The purpose of the procedure is to place a tube to equalize the pressure in the middle ear and allow for drainage. There is no bandage that needs to be replaced. The remaining instructions are correct for this procedure, or for care of a 2-year-old. Aspirin should never replace Tylenol because of the potential for Reyes syndrome. 87. A 9-year-old child is recovering from a tonsillectomy. The nurse notes that the child is swallowing frequently. What is the nurse’s next action? A. Call the health care provider. B. Suction the child’s oral cavity. C. Instruct the child to cough. D. Place in a side-lying position. Rationale: The child is showing signs of bleeding from the operative site. To prevent aspiration turn the child prone or to a side- lying position. If bleeding is confirmed, then notify the health care provider. Only suction the oral cavity in the presence of an obstruction. Suctioning can cause more damage to the operative site. Coughing will irritate the site. 88. A child presents to the school nurse with a bloody nose, which occurred spontaneously. What actions will the nurse take for this child? (Select all that apply.) A. Assist the child to a lying position on a school cot. B. Have the child pinch the nose closed tightly. C. Prepare a warm compress to apply to the nose. D. Set the timer for 10 minutes. E. Locate the water-soluble jelly in the clinic. Rationale: The child must be in an upright position to prevent aspiration. Cool compresses or ice packs can help constrict the area and decrease the flow of blood. The remaining steps re appropriate for a bloody nose. The nurse must remain calm. If the child senses the nurse is agitated, then the child might become agitated and then become uncooperative. 89. The nurse is assessing a 3-year-old presenting to the emergency department with agitation, a cherry red and edematous epiglottis, and a high fever. What focuses assessments will the nurse include in this child’s plan of care? (Select all that apply.) A. Respiratory rate B. Use of accessory muscles when breathing C. Babinski reflex D. Bowel sounds E. Breath sounds Rationale: This child is presenting with signs of epiglottitis. The hallmark sign is the cherry red and edematous epiglottis. This can lead to a severely restricted or occluded airway. The focused assessment is of the respiratory system. The Babinski reflex is a neurologic sign. Bowel sounds are a gastrointestinal sign. The remaining assessments are included in a focused respiratory assessment. 90. A nurse in the emergency department is working with a nursing student. Which student action will the nurse need to correct when caring for a child with epiglottitis? A. Take an oral temperature. B. Place the pulse ox on the earlobe. C. Take away oral fluids from the bedside. D. Place cool mist oxygen therapy. Rationale: The child is at risk for an occluded airway as spasm of the epiglottitis can occur. The nurse should not take an oral temperature, obtain a throat culture or hyperextend the neck, and open the mouth wide. Pulse ox is needed and the earlobe is an appropriate place for the sensor. The child needs to be NPO and cool oxygen mist can help decrease the swelling. 91. A nurse is caring for a 3-year-old child newly admitted to the emergency department (ED) with labored respirations, a continuous respiratory stridor, sternal retractions with inspiration, and restlessness. What immediate actions will the nurse take for this child? (Select all that apply.) A. Place the head of the bed up 45 degrees. B. Assess the child’s oxygen saturation. C. Assess for exposure to bacterial meningitis. D. Instruct parents to use a cool air vaporizer. E. Assess for pallor and cyanosis. Rationale: This child is showing signs of significant respiratory distress. A focused assessment on the respiratory system is necessary. Common causes for these presenting conditions are flu viruses A and B, respiratory syncytial virus, and mycoplasma pneumonia. Assessing for exposure to bacterial meningitis is not relevant with these symptoms. Instructing the parents to use a cool air vaporizer is a discharge instruction, but not appropriate for the initial assessment for the ED. 92. After a 3-day hospitalization for croup, secondary to mycoplasma pneumonia, the nurse is working with the parents to discharge the child home. The parents state to the nurse, “we do not have the money to purchase the right kind of vaporizer.” What is the nurse’s best action? A. Give the parents $30 cash from a personal fund. B. Ask, “Do you have a freezer with your refrigerator?” C. Ask, “Do you have any relatives nearby that could purchase the vaporizer.” D. Give the parents an old hospital vaporizer with warm, moist heat. Rationale: An alternative to cool mist is breathing in cool air from a freezer, cool night air, or cool air from a basement. Giving any client personal cash is a breech between clients and patients. Getting relatives to purchase the vaporizer is an alternative, but does not address the immediate issue of cool air for the child. A warm, moist vaporizer is not appropriate for this child. 93. The charge nurse is planning the placement of a child for admission from the emergency department with respiratory compromise of unknown origin. What is the best bed placement for this child’s admission? A. Single room away from the nurse’s station, but close to another child with respiratory compromise B. Single room close to the nurse’s station, and away from any other children with respiratory issues C. Double room, second bed unoccupied, and no scheduled surgical admissions planned for the day D. Double room, with a 24-hour parental watch of the child in the opposite bed Rationale: This child needs to be isolated until diagnosis of the underlying cause for the respiratory compromise. Then, the child can share a room with another child with the same infection. Close to the nurse’s station is preferred since the child will require close observation. While the double room is available now, there is no guarantee that the bed will not be needed. 94. A 2-year-old child is placed in an oxygen tent. What clothes will the nurse recommend the parents bring from home for the child? A. An all-cotton sleeper B. A synthetic shirt and baggy shorts C. A polyester play outfit D. A lightly woven wool sweater Rationale: The child will be in an environment of cool, moist air. Cotton is a breathable fabric appropriate for this environment. Polyester and synthetic fibers will trap the cool moisture. Wool will make the child feel cold when it gets moist. 95. A child presents again to the school nurse with dyspnea, wheezing, diaphoresis, and deep dark-red lips. What is the next nursing action? A. Call the child’s parents. B. Call 911. C. Ask, “Do you have your inhaler?” D. Ask, “Did you play outside today?” Rationale: This child is showing signs of respiratory distress, possibly asthma (deep read lips). Rapid relief medications such as a bronchodilator followed by steroids may help alleviate the symptoms. Because the child presents again, indicates this child is known to the nurse. The nurse must assess for patency of the airway. Calling the child’s parents does nothing for the airway. Emergency treatment through from paramedic may be indicated if the child does not have any rapid relief medications. Playing outside may trigger an asthma attack, but does nothing to treat the respiratory distress. 96. A child is preparing for discharge from the hospital with the primary diagnosis of asthma. What will the nurse include in the child’s discharge plan? (Select all that apply.). A. Home assessment for environmental allergens B. Move the child into a single bedroom. C. Clean the corticosteroid dispenser once a month. D. Teach the parents about peak expiratory flow rates. E. Increase the amount of daily carbohydrates and proteins. Rationale: Medication dispensers, especially those delivering corticosteroids, need cleaning after every use to prevent the development of yeast infections. The child needs a balanced diet with plenty of fluid to liquefy secretions. Assessment of the home for environmental allergens helps decrease the risk for an asthma attack. Keeping the child away from respiratory infections is important and exposure can be decreased if not exposed to a sibling with infections. A decrease in expiratory flow rate may indicate a pending asthma attack. 97. The nurse is reviewing the laboratory results for a child admitted to rule out cystic fibrosis. Which test result should the nurse bring to the immediate attention of the health care provider? A. Serum sodium level of 135 mEq/L B. Serum sodium level of 145 mEq/L C. Sweat chloride concentration of 20 mEq/L D. Sweat chloride concentration of 80 mEq/L Rationale: A sweat chloride concentration of greater than 60 mEq/L is a positive result for cystic fibrosis. The remaining values are within the normal range. 98. The nurse is planning care for the four clients assigned. Which nursing action takes priority? A. Chest physiotherapy upon awakening for the child with cystic fibrosis B. Administration of acetaminophen for the child with a temperature of 99°F/37.2°C C. Discharge teaching to the parents of a toddler after treatment for influenza type A D. A bronchodilator treatment for a child with stabilized asthma Rationale: Secretions often thicken with the inactivity of sleep. This child is the priority because the airway will likely be compromised without the chest physiotherapy. The acetaminophen is necessary, but this child’s fever is low and is not of the greatest priority. Discharge teaching is the lowest priority as this child is stable for discharge. The bronchodilator treatment is the second priority. Since this child is stable, this does not rise to first priority. 99. The nurse is teaching a group of new first-time parents about sudden infant death syndrome (SIDS). What will the nurse include in the teaching plan? (Select all that apply.) A. Boys are at higher risk for SIDS than girls. B. The high-risk period is after 9 months of age. C. Do not place the baby to sleep on its tummy. D. Napping on the sofa is acceptable. E. Sleeping with your newborn is encouraged. Rationale: The high-risk period for SIDS is 2 to 3 months of age. Place infants in a supine position for sleep. Sleeping in soft, overstuffed furniture places an infant at higher risk for SIDS. Co-sleeping is discouraged, and it places the infant at higher risk for SIDS. The remaining statements are true. 100. How will the nurse plan to position a child with left sided pneumonia? A. On the child’s right side B. On the child’s left side C. Head of the bed up at a 90 degrees angle D. Prone, with pillows placed bilaterally Rationale: Placing the child on the affected side decreases discomfort in the pleural area. 101. The nurse is providing care for an infant started on digoxin. The am assessment of this child included poor feeding and vomiting, and a heart rate of 96 beats/min. The am digoxin level is 2.3 ng/mL. What is the nurse’s next action? A. Hold the am dosage of digoxin. B. Notify the health care provider. C. Assess for a dysrhythmia. D. Administer 30 mL of sterile water. Rationale: The digoxin level is at the toxic and can be a medical emergency. Infants need to be watched closely for toxicity. While the next dose may be held, the health care provider must first be notified to prescribe that action. Assessing for a dysrhythmia does not add any additional information. Sterile water is non-nutritive for an infant with poor feeding and vomiting. 102. The nurse is reviewing meal planning with a mother whose child is on furosemide. What high potassium selections will the nurse encourage the mother to include in the child’s diet? (Select all that apply.) A. Bananas B. Mandarin oranges C. Strawberries D. Green peas E. Raisins F. Blueberries Rationale: High potassium fruits include apricots, bananas, cantaloupe, dried fruit (including raisins), honeydew melon, kiwi, mango, nectarines, oranges and orange juice, papaya, prunes, and pumpkin. 103. The nurse is preparing discharge instructions for parents of an infant scheduled for discharge on oral digoxin. What instructions will the nurse include in the plan? (Select all that apply.) A. Use a household spoon to deliver the medication. B. Administer 1 hour before a feeding. C. Mix the medication in with the infant’s formula. D. Call your pediatrician if you miss two doses. E. Keep the medication in a locked cabinet. Rationale: Use an accurate measure for dispensing the medication, such a needleless syringe. Do not mix the medication with food or formula. Administration of digoxin is 1 hour before or 2 hours after a meal. The remaining instructions are correct. 104. The nurse is reviewing laboratory values of a child just started on furosemide. The child’s serum potassium level is 4.2 mEq/L. What is the nurse’s next action? A. Notify the health care provider. B. Hold the next dose of furosemide. C. Document the finding in the nurse’s notes. D. Assess the child for cramping and confusion. Rationale: The normal value for potassium in a child is the same as that of an adult of 3.5 to 5.0 mEq/L. This value requires no additional action other than documenting the normal level. Cramping and confusion occur when the serum potassium levels are low. 105. An infant is admitted with the medical diagnosis of coarctation of the aorta. What findings from the child’s initial assessment support this medical diagnosis? (Select all that apply.) A. Dilated scalp veins B. Separated cranial suture lines C. Bulging anterior fontanels D. Bounding pulses in the arms E. Cool lower extremities Rationale: Coarctation of the aorta includes a narrowing of the aorta near is ductus arteriosus. There is a decrease in the blood pressure to the lower body. Dilated scalp veins, separated suture lines, and bulging fontanels are symptoms associated with increased intracranial pressure and do not relate to this child’s diagnosis. 106. A 10-month-old is admitted for a tetralogy of Fallot repair. Which postoperative finding indicates that the repair is successful? (Select all that apply.) A. Absence of cyanosis when feeding B. Presence of a heart murmur C. Lips are pink when crying D. Heart rate 126 beats/min E. Respiratory rate 32 breaths/min Rationale: The heart murmur associated with tetralogy of Fallot should be resolved after the repair. The cyanosis with feeding, crying, and defecation should resolve. Vital signs are normal as there is no need to compensate for the congenital defect. 107. What assessment will the nurse include in a child’s care plan who is admitted with rheumatic fever? A. Recent bruising to the knees B. Sore throat in the past 2 to 6 weeks C. Recurring headaches, 2 to 3/week D. Dark brown or rusty colored urine Rationale: Rheumatic fever often results form an untreated β-hemolytic streptococcal upper respiratory infection. Bruising of the knees is related to hemophilia. Recurring headaches can be associated with many neurological disorders. Rusty colored urine is seen with kidney problems such as glomerulonephritis. 108. The nurse is evaluating the teaching given to the parents of a child with glomerulonephritis. Which parent statement will the nurse need to correct? (Select all that apply.) A. Weigh at the same time every day. B. Use the same scale for daily weights. C. Wait 2 to 3 days to report rusty-brown urine. D. See the health care provider if a sore throat develops. E. Report facial edema that occurs in the evening. Rationale: The presence of frothy, rust colored urine is a sign of nephrotic syndrome. With nephrotic syndrome, facial edema occurs in the morning. Measurement of fluid balance is accurate if weights occur at the same time each day, on the same scale, with the same clothing. All infections, especially sore throats need to be reported to evaluate for β- hemolytic streptococcal infections. 109. The nurse is conducting meal planning for a child scheduled for discharged after treatment for acute glomerulonephritis. What foods are appropriate for this child? (Select all that apply.) A. Lean beef B. Chicken without the skin C. Brown rice D. Movie-style popcorn E. Regular canned green beans F. Carrots Rationale: Because of the fluid retention associated with this diagnosis, foods need to be low in sodium. Movie-style popcorn and canned green beans have added salt and are not recommended for this dietary plan. Popcorn is permissible without salt or butter. No added salt green beans are recommended for this diet. 110. A mother reports to the clinic nurse persistent nighttime bed wetting for her 6-year-old child. What focused assessments will the nurse include in the child’s initial evaluation? (Select all that apply.) A. Have the mother conduct a 48-hour diet recall. B. Determine the amount of fluid intake after 1800. C. Ask if the child urinates just before bedtime. D. Ask about the onset of the bedwetting. E. Obtain a clean catch urine sample. F. Ask if the child has started riding a bicycle. Rationale: Dietary recall is generally conducted to determine the child’s nutritional habits. Riding a bicycle is associated with musculoskeletal and neurologic development. While both of these help with determining growth and development, they are not associated with a focused assessment for nocturnal enuresis. Nighttime bladder control is usually achieved by 5 years. A clean catch urine is to determine the presence of an infection that may cause the enuresis. The remaining assessments relate to enuresis. 111. The nurse is providing care to a newborn with hypospadias. Which parent statement indicates the nurse’s teaching has been successful? A. I will not be able to beast feed my baby at all. B. A circumcision will not be performed before discharge. C. We will need to undergo genetic testing for future children. D. I will call the doctor if my baby’s heart rate is above 150. Rationale: A hypospadias is a genital anomaly of the urinary meatus placement below the glans. The foreskin removed with circumcision can be used in the surgical reconstruction. Breast feeding is permissible with this condition. Genetic counseling is not necessary as the exact cause of hypospadias is not known. A heart rate of 150 is normal for an infant. 112. What assessment findings will the nurse expect to see in a 9-month-old with cerebral palsy? (Select all that apply.) A. Absence of the Moro reflex B. Presence of the Babinski reflex C. Presence of the tonic neck reflex D. Irritability and excessive crying E. Rigidity of the arms and legs F. Coordinated suck-swallow when feeding Rationale: For the infant with cerebral palsy (CP) infantile reflexes remain after 6 months. The nurse may observe both the Moro and the tonic neck reflexes in these infants. The Babinski reflex does not disappear until approximately 1 year of age. Infants with CP are often irritable, cry for no apparent reason. Muscle tone of the arms and legs is altered and displayed as rigid. Because of the abnormal motor development and coordination, feeding can be challenging. 113. A nine-year-old is admitted to the emergency department with blunt force trauma to the skull from a bike accident. Which assessment finding is most reassuring to the nurse? A. Vital signs are heart rate of 84 and respiratory rate of 16. B. Presence of a headache and visual changes C. Pupil size is unequal and sluggish. D. Alert and oriented to person, place, time, and situation Rationale: The nurse needs to assess for signs if increased intracranial pressure (ICP). The most reassuring sign is the child’s level of consciousness. The vital signs are normal, which is also good, but does not directly reflect ICP. Headache, visual changes, unequal and sluggish pupils are signs of increasing intracranial pressure. 114. The nurse is providing care to a 9-year-old newly admitted to the emergency department with a closed head injury. Which of the health care provider’s orders will the nurse question? (Select all that apply.) A. Neuro checks every 8 hours B. Two milligrams of IV morphine x one now C. Turn off the florescent lighting in the room. D. Increase the head of the bed to 45 degrees. E. Parents at the bedside Rationale: Initial neuro checks need to be performed at least hourly to detect for subtle changes. Sedating medications like morphine need to be avoided during the initial phase of assessment of a closed head injury. The head of the bed should only be elevated 15 to 30 degrees. The goal is to decrease stimulation in the room by turning off the florescent lighting. Subtle lighting can be brought into the room. Parents at the bedside will offer the child reassurance. 115. Which statement by the older school-age child indicates to the nurse the teaching was effective for seizure precautions? (Select all that apply.) A. “I will wear my helmet with my wrist and shin guards when I ride my bike.” B. “I can never ride my skateboard again or watch my friends skateboard.” C. “I will wear my medical ID bracelet only when I am outside of the house.” D. “I will always swim with a friend or family member; I will never swim alone.” E. “I will make sure I take my seizure medication when I brush my teeth at night.” Rationale: Skateboarding is permissible with the appropriate protection. The medical alert ID should be worn at all times. Taking it on and off increases the likelihood of forgetting to wear it. Biking, skateboarding, and in-line skating are allowable with the appropriate protection and in controlled settings. A seizure unattended in the water could be life threatening. Associate taking medication with other daily routines to increase compliance. 116. The nurse checks the fluid from the nose of the client newly admitted to the emergency room after a motor vehicle accident. Which positive finding would be most concerning to the nurse? A. Protein B. Glucose C. Blood D. pH 7.4 Rationale: The presence of glucose in drainage from the ear or nose after a head injury is indicative of cerebral spinal fluid. The health care provider must be notified immediately with this finding. The remaining values are suggestive of blood. 117. The nurse is providing care to an infant is recovering from a shunt placement for hydrocephalus. Which actions will the nurse include in the immediate postoperative care of this infant? (Select all that apply.) A. Measure head circumference. B. Place infant on the operative side. C. Assess neurological signs every hour. D. Keep the infant flat. E. Stimulate the infant to cry every hour. Rationale: The infant needs to be placed on the non-operative side to prevent pressure on the shunt valve. The child does not need to cry to assess neuro signs. Provide comfort measures and decrease stimulation. The remaining actions are appropriate care for this infant. 118. An infant post shunt replacement for hydrocephalus suddenly awakens with a high pitched, shrill cry and cannot be comforted. What is the next nursing action? A. Bring the parents to the infant’s bedside. B. Contact the health care provider. C. Monitor the infant’s intake and output. D. Pat the infant gently on its back. Rationale: A high pitch, shrill cry is an indication of increased intracranial pressure. The shunt is not functioning as it is designed and the health care provider must be informed. While the parents can comfort the infant, they can do nothing about the malfunctioning shunt. I & O is a cardiovascular assessment and is not included in the immediate neurological focused assessment for this infant. Comfort measure to stop the crying does not address the neurologic concern in this infant. 119. The nurse comes upon a hospitalized child having tonic-colonic movements. The child has a history of seizure activity. What actions will the nurse take for this child? (Select all that apply.) A. Place a pillow under the child’s head. B. Place an airway while the child continues to seize. C. Hold the child down during the seizure. D. Unbutton the top button of the child’s shirt. E. Place the child on the side after the seizure is over. F. Leave the child to get help from the unit across the hall. Rationale: Do not place anything in the child’s mouth during a seizure. If an airway is available, place it after the seizure. Do not attempt to restrain the child. Remove any dangerous objects from the immediate area and allow the seizure to take its course. Never leave a seizing child. Seizures are self-limiting and the nurse needs to observe the seizure and provide post-seizure care. If clothing is restrictive, attempt to loosen the clothing. 120. What is the best position for the nurse to place a newborn with a meningocele? A. Prone B. Left side lying C. Right side lying D. Supine Rationale: A meningocele is a protrusion of a sac at the base of the newborn’s spine that contains the meninges and CSF. The infant needs to be prone with the head turned to the side to minimize tension on the sac. 121. The clinic nurse is reviewing information with parents whose child was recently diagnosed with autism spectrum disorder. Which statements by the parents indicate to the nurse that they understand the teaching? (Select all that apply.) A. “Repetitive movements are common.” B. “Loves to interact with same age children.” C. “Non-verbal communication is limited.” D. “Frequently reaches out to be comforted.” E. “Maintain a daily routine whenever possible.” Rationale: A child with an autism spectrum disorder does not socialize well with others. They do not seek comfort. The remaining characteristics are common with children on the autism spectrum. 122. The nurse is performing a newborn assessment. A clicking sensation is noted when abducting the child’s thigh and placing gentle pressure over the greater trochanter. How will the nurse document this finding? A. Positive Barlow’s test B. Positive Ortolani maneuver C. Positive Homan’s sign D. Positive Galeazzi’s sign Rationale: This movement describes the Ortolani maneuver to assess for instability of the hip. Barlow’s test performs a similar maneuver only pressure is applied down and back with the examiner’s thumbs. Homan’s sign tests for the possibility of a blood clot in the leg. Galeazzi’s sign reveals a shortening of the limb on the affected side. 123. What actions will the nurse include in the care plan of a 12-year-old with juvenile idiopathic arthritis? (Select all that apply.) A. Encourage jogging as a form of exercise. B. Apply cold packs to the affected joints. C. Position the affected joints in a neutral position. D. Warm shower or bath in the morning upon rising. E. Limit NSAIDs to avoid dependence. Rationale: While the child is encouraged to perform normal activities of daily living, the child needs to consider non-weight bearing exercise such as biking or swimming. NSAIDs are the first line of medication to treat the arthritis and they are non-habit forming. Cold packs can reduce swelling. A neutral position of the joints maintains alignment. Stiffness and swelling are often worse in the morning, upon arising. A warm bath or shower can help decrease the stiffness. 124. The health care provider prescribes digoxin 0.05 mg/kg/day in two equally divided doses. The child’ weight is 18 pounds. How many mg will the nurse administer in one dose? 0.2 (Round to the nearest tenth.) Rationale: 125. The health care provider orders ampicillin 10 mL three times a day for a 16.5 pound infant. The label on the ampicillin bottle reads 125 mg per 5 mL. How many milligrams will the infant receive in 1 day? 750 mg Rationale: [Show More]

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