A nurse in a providers office is preparing to administer immunizations to a toddler during a well child visit. Which of the following actions should the nurse plan to take?
Provider Prescriptions​:
Tuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineInactivated influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine
Graphic Record:
Respiratory rate 24/minHeart rate 115/minTemperature 36.9° C (98.4° F)
History and Physical:
​Age 15 months Height 71.1 cm (28 in) Allergies Neomycin (anaphylactic reaction) Caregiver reports rhinitis with clear nasal drainage for 2 daysOccasional nonproductive cough for 2 days History of asthma
answer
Withhold the MMR Vaccine.
Th nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR Vaccine. Clients who have severe allergy to eggs or gelatin should not receive this vaccine.
question
A nurse is providing teaching to a parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?
answer
"Shake the medication prior to administration"
The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.
question
A nurse is reviewing the lumbar puncture results of a school age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?
answer
Increased protein concentration.
The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
question
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
answer
"Your daddy will be back after you eat"
Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime.
question
A nurse is reviewing the lab report of a school age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
answer
Hematocrit 28%
The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school age child. Child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, & pallor due to decreased oxygen carrying capacity
question
A nurse is reviewing the laboratory report of an infant who is receiving the treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
answer
sodium 140 mEq/L
The nurse should identify that a sodium level of 140 is within the expected reference range of 134 to 150 and indicates the current treatment for dehydration is effective.
question
A nurse is reviewing the lab report of a 7year old who is reviving chemo. Which of ht e following lab values should the nurse report to the provider?
answer
HgB 8.5 g/dL
A child receiving chemo is at risk for anemia due to the chemo effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through lab testing of hemoglobin and hematocrit levels. Expected range is 10-15.5 g/dL for a 7year old.
question
A nurse is teaching the parent of an infant about ways to prevent sudden infant syndrome (SIDS). Which of the following instructions should the nurse include?
answer
"Give the infant a pacifier at bedtime."
The nurse should inform the parent that protective factors against SIDS includes breastfeeding and the use of a pacifier when the infant is sleeping.
question
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?
Place the steps incorrect order.
answer
1. Turn off IV Pump
2. Occlude the IV tubing.
3. Remove the tape securing the catheter.
4. Apply pressure over the catheter insertion site.
question
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
answer
Denies discomfort during assessment of injuries.
The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.
question
A nurse is teaching a parent of an infant who has a pavlik harness for the treatment of development dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
answer
"I will place my infants diapers under the harness straps"
To prevent soiling of the harness, the parent should apply the infants diaper under the straps.
question
A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect?
answer
Abdominal Distention
The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, & restlessness.
question
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
answer
A unilateral rib hump.
When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S or C shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis.
question
A nurse is assessing a school age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
answer
Absence of peristalsis.
The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowl resumes functioning.
question
A nurse is providing discharge teaching to the parent of child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?
answer
Speech Therapist
A child who has a cleft palate will require speech therapy immediately following the repair to support speech development & future articulation.
question
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschoolers parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?
answer
"Lets talk about some of the ways you have handled previous stressors in your life."
This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
question
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
answer
Apply topical analgesic cream to the site 1 hr prior to the procedure.
This decreases the adolescents pain while the lumbar needle is inserted.
question
A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
answer
Substernal retractions.
When using the airway, breathing and circulation approach to client care, the nurse should determine priority finding to report to the provider is substernal retractions. The finding indicates the newborn is experiencing increased respiratory effort, wi=which could quickly progress to respiratory failure.
question
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
answer
Playing dress-up
At preschool age, play should focus on social, mental and physical development. Therefore, playing dress-up is a recommended play activity for this child.
question
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?
answer
Implement seizure precautions for the infant.
An infant who has an epidural hematoma is at great risk for seizure activity.
question
A nurse is admitting a school age child who has pertussis. Which of the following actions should the nurse take?
answer
Initiate droplet precautions for the child.
Also known as whopping cough, it is transmitted through contact with infected large droplet nuclei that are suspended in the air when the child cough, sneezes or talks.
question
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for a wound debridement following a burn. Which of the following actions should the nurse tae prior to the procedure?
answer
Administer an analgesic to the child.
Hydrotherapy for debridement of a wound is extremely painful which requires analgesia and/or sedation.
question
A nurse is caring for a 15 year old client who is married and scheduled for a surgical procedure. The client asks, who should sign my surgical consent? which of the following responses should the nurse make?
answer
"You can sign the consent because you are married."
Marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents.
question
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicated an understanding of the teaching?
answer
I should keep. my child indoors when i mow the yard.
Guarding against exposure to known allergens found outdoors such as grass, trees, & pollen will decrease the frequency of asthma attacks.
question
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. which of the following nutritional items should the nurse offer to the toddler?
answer
Oral rehydration solution.
A toddler who has acute diarrhea should consume oral rehydration to replace electrolytes and water by promoting the reabsorption of water and sodium.
question
A nurse is caring for a school age child who has experienced a tonic clonic seizure. Which of the following actions should the nurse. take during the immediate postictal period?
answer
Place the child in a side lying position.
Prevents aspiration
question
A nurse is planning care for a school age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
answer
Initiate seizure precautions for the child.
A sodium level of 129 indicates hyponatremia and places the cild at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement precautions to maintain the Childs safety.
question
A nurse is caring for a school age child who is receiving cefazolin via intermittent IV bolus. the child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the med infusion, which of the following meds should the nurse administer first?
answer
Epinephrine.
This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
question
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
answer
Loud, Harsh murmur.
The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
question
A nurse is assessing the vital signs of a 10 year old child following a burn injury. the nurse should identify which of the following findings is an indication of early septic shock?
answer
Temp. 39.1 C (102.4 F)
The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.
question
A nurse is preparing to collect a sample from a toddler for a sickle turbidity test. Which of the following actions should the nurse plan to take?
answer
Perform a finger stick.
The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
question
A nurse in the emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurneys point?
answer
This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.
question
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney.
answer
Serum creatinine 3.0 mg/dL
Creatinine is a by product of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.
question
A nurse is caring for an infant who has respiratory syncytial virus (RSV). which of the following actions should the nurse implement for infection control?
answer
Have a designated stethoscope in the infants room.
The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
question
A nurse is teaching the parents of a school age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching?
answer
My child will receive antibiotics for several weeks.
Osteomyelitis is infection in the bone. The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.
question
A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
answer
I should secure the car seat using the lower anchors and tethers instead of the seat belt.
Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.
question
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
answer
Dry, hacking cough
This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
question
A nurse is creating a plan of care for a school age child who has heart disease and has developed HF. Which of the following interventions should the nurse include in the plan?
answer
Provide small, frequent meals for the child.
The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.
question
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?
answer
Zinc Oxide
Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
question
A nurse in an emergency department is caring for a toddler who has a partial thickness burs on their right arm. Which of the following actions should the nurse take?
answer
Cleanse the affected area with mild soap and water.
The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
question
A nurse is caring for a 15 yr old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
answer
Mental Confusion
A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.
question
A nurse is preparing to administer an immunization to a 4 yr old child. Which of the following actions should the nurse plan to take?
answer
Administer the immunization using a 24 gauge needle.
The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.
question
A nurse is assessing a school age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
answer
Petechiae on the lower extremities.
The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
question
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
answer
Tachypnea.
When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
question
A nurse is auscultating the lungs of an adolescent who has asthma. the nurse should identify the sound as which of the following?
*fast breathing
answer
Tachypnea
The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
question
A nurse is assessing a 3 yr old toddler at a well child visit. Which of the following manifestations should the nurse report to the provider?
answer
Respiratory rate 45/min.
The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
question
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
answer
Schedule the child for a yearly rescreening.
The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
question
A nurse is caring for a school age child who is in Bucks traction following a leg fracture 24 hrs hours. Which of the following actions should the nurse take?
answer
Assess peripheral pulses once every 4hrs.
Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.
question
A nurse is assessing a 4 yr old child at a well child visit. Which of the following developmental milestones should the nurse expect to observe?
answer
Cuts an outlined shape using scissors.
The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.
question
A charge nurse in an emergency department is preparing an inservice for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?
answer
Symmetric burns of the lower extremities
The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
question
A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
answer
I will give myself a shot of regular insulin 30 mins before I eat breakfast.
The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
question
A nurse in an emergency department is caring for a school age child who has appendicitis and rates their abdominal pain as a 7 on a scale of 0-10. Which of the following actions should the nurse take?
answer
Give morphine 0.05 mg/kg IV.
A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.
question
A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
answer
The toddler received tobramycin during a hospitalization 2 weeks ago.
The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
question
A nurse is providing dietary teaching to the parent of a school age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
answer
White rice
The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.
question
A nurse in an emergency department is caring for a school age child whois experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
answer
Administer epinephrine IM to the child.
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.
question
A nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school age child who weighs 75lbs. Avail. is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (round to nearest whole #)
answer
1 capsule
question
A nurse is caring for a school age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
answer
Flank Pain
The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
question
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect?
answer
1. Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed.
2. Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes.
3. Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.
question
A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
answer
Screen the Childs visitors for indications of infection.
A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.
question
A nurse is receiving change of shift report to four children. which of the following children should the nurse see first?
answer
A school-age child who has sickle cell anemia and reports decreased vision in the left eye
When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
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