Nurse Bao is preforming education for the parents of an infant with bladder exstrophy. Which statement by the parents would indicate an understanding of the child's future care?
"Care will be no different than that of any other infant."
"My infant will only need this one surgery."
"My child will wear diapers all his life."
"We will need to care for the urinary diversion."
A 4-year-old girl presents with recurrent urinary tract infection. A prior workup did not reveal any urinary tract abnormalities. What is the priority nursing action?
Obtain a sterile urine sample after completion of antibiotics.
Teach appropriate toileting hygiene.
Prepare the child for surgery to reimplant the ureters.
Administer antibiotics intramuscularly.
A 5-year-old who had a renal transplant 9 months ago and has no history of chickenpox presents to the pediatric clinic for his vaccinations. Which is the most appropriate set to give?
DTaP, IPV, MMR, varicella
DTaP, IPV, varicella
When nurse Steve is caring for a child with hemolytic-uremic syndrome or acute glomerulonephritis and the child is not yet toilet trained, which action by nurse Steve would best determine fluid retention?
Test urine for specific gravity
Weight child daily
Weigh the wet diapers
Measure abdominal girth daily
A boy with Duchenne muscular dystrophy is admitted to the pediatric unit. He has an ineffective cough. Lung auscultation by nurse Laura reveals diminished breath sounds. What is the priority nursing intervention?
Apply supplemental oxygen
Notify the respiratory therapist
Monitor pulse oximetry
Position for adequate airway clearance
A 7-year-old child with cerebral palsy has been admitted to the hospital. Which information is most important for nurse Tanya to obtain in the history?
Age that the child learned to walk
Parents' expectations of the child's development
Functional status related to eating and mobility
Birth history to identify cause of cerebral palsy
Nurse Kevin is caring for a 2-year-old with myelomeningocele. When teaching about care related to neurogenic bladder, what response by the parent would indicate that additional teaching is required?
"Routine catheterization will decrease the risk of infection from urine staying in the bladder."
"I know it will be important for me to catheterize my child for the rest of her life."
"I will make sure that I always use latex-free catheters."
"I will was the catheter with warm soapy water after each use."
Nurse Jessica is caring for a child with cerebral palsy who requires a wheelchair to attain mobility. Which intervention would help the child achieve a sense of normality?
Encourage follow-through with physical therapy exercises
Restrict the child to a special needs classroom
Encourage after-school activities within the limits of the child's abilities
Ensure the school is aware of the child's capabilities
What is the priority nursing intervention for the child recently admitted with Guillain-Barré syndrome?
Perform range-of-motion exercises
Take temperature every 4 hours
Monitor respiratory status closely
Assess skin frequently
Nurse Mar is evaluating a parent's understanding of treatment for torticollis. Which response best indicates that the parent understands the appropriate treatment?
Encourages the infant to turn the head to the unaffected side
States that prone positioning for sleep will be needed
Places the infant on the affected side
Stretches the infant's neck to the opposite side and holds it for 5 seconds
Nurse Michelle is providing education related to use of a brace that the orthopedic surgeon has ordered as treatment for idiopathic scoliosis in an adolescent girl. Which statement by the teen best indicates an understanding of appropriate use of the brace?
"I can take my brace off only for special occasions."
"I will take my brace off for only 1 hour per day, for showering."
"I do not need to wear my brace at night while I am sleeping."
"It is most important for me to wear my brace during the day, while I am upright."
Nurse "Z" is caring for orthopedic children who are in the postoperative period following spinal fusion. What is the most appropriate activity to delegate to unlicensed assistive personnel?
Ambulate the children twice daily to promote mobility
Encourage commode use to promote bowel function
Provide diversionary activities, as the children must stay flat on their backs
Assist with log-rollig the children every 2 hours
Nurse Angela is caring for a child with a fractured left femur who has been in skeletal traction for several days. Upon assessment, she notes that the left foot is pale, with a nonpalpable pedal pulse. What is the priority nursing intervention?
Release the traction, as there may be too much weight on it
Nothing; alterations in circulation are expected with skeletal traction
Immediately notify the physician or nurse practitioner of this abnormal finding
Massage the food immediately to increase circulation
Nurse Hillary is teaching about skin care for atopic dermatitis. Which statement by the parent indicates that further teaching may be necessary?
"I will use Vaseline or Crisco to moisturize my child's skin."
"A hot bath will soothe my child's itching when it is severe."
"I will buy cotton rather than wool or synthetic clothing for my child."
"I will apply a small amount of the prescribed cream after the bath."
Nurse Shelly is caring for a child who has received significant partial-thickness burns to the lower body. What is the priority assessment in the first 24 hours after injury?
Nurse Hannah is caring for a child in the emergency department who was bitten by the family dog, who is fully immunized. What is the priority nursing action?
Administer rabies immunoglobulin
Refer the child to a counselor
Assess the depth and extent of the wound
Administer a tetanus booster
Nurse Carina is caring for an infant on the pediatric unit who has a very red rash in the diaper area, with red lesions scattered on the abdomen and thighs. What is the priority nursing intervention?
Administer griseofulvin with a fatty meal
Institute contact isolation precautions
Apply topical antibiotic cream
Apply topical antifungal cream
A varsity high-school wrestler presents with a "rug burn" type of rash on his shoulder that is not healing as expected, despite use of triple antibiotic cream. Two other wrestlers on his team have a similar abrasion. What infection should nurse Chrissy be most concerned about, based on the history?
A child on the pediatric unit has morning laboratory results of Hgb 10.0, Hct 30.2, WBC 24,000, and platelets 20,000. What is the priority nursing assessment?
Assess for pallor, fatigue, and tachycardia
Monitor for fever
Assess for bruising or bleeding
Determine intake and output
A child with hemophilia fell while riding his bicycle. He was wearing a helmet and did not lose consciousness. He has a mild abrasion on his knee that is not oozing. He is complaining of abdominal pain. What is the priority nursing assessment?
Perform neurological checks
Assess ability to void frequently
Carefully assess his abdomen
Examine his knee frequently
A 14-year-old with thalassemia asks for nurse Kelly's assistance in choosing her afternoon snack. Which choice is the most appropriate?
Peanut butter with rice cake
Small spinach salad
Apple slices with cheddar cheese
Small burger on wheat bun
Nurse Angelica is caring for a child who has just been admitted to the pediatric unit with sickle cell crisis. He is complaining that his right arm and leg hurt. What is the priority nursing intervention?
Administer pain medication every 3 hours intravenously until pain is controlled
Perform passive range of motion of the arm and leg to maintain function
Try acetaminophen for pain first, moving up to opioids only if needed
Use narcotic analgesics and warm compresses as needed to control the pain
Nurse Bryn is caring for a 6-year-old with juvenile idiopathic arthritis. The mother states that she has trouble getting her daughter out of bed in the morning and believes the girl's behavior is due to a desire to avoid going to school. What is the best advice by the nurse?
Refer the girl to a psychologist for evaluation of school phobia related to chronic illness
Administer a warm bath every morning before school
Give the child her prescribed NSAIDS 30 minutes before getting out of bed
Allow her to stay in bed some mornings if she wants
A 14-year-old with systemic lupus erythematosus wants to know how to care for her skin. What should the nurse teach this adolescent?
Careful sun tanning will give her skin an attractive color
No special skin care is needed
Use sunscreen daily to avoid rashes
Use makeup to camouflage the butterfly rash on her face
The mother of a child with hypogammaglobulinemia reports that her child had a fever and slight chills with an intravenous gammaglobulin infusion last month. She wants to know what other course of treatment might be available. What is the best response by nurse Oziel?
Administration of acetaminophen or diphenhydramine prior to the next infusion may decrease the incidence of fever or chills
Giving the gammaglobulin intramuscularly is recommended to prevent a reaction
Talk to her physician or nurse practitioner about alternative medications that may be used to boost the gammaglobulin level in the blood
If the child is no longer experiencing frequent infections, then the IV infusions may not be necessary
A 4-month-old infant born to an HIV-infected mother is going into foster care because the mother is too ill to care for thie child. The foster mother wants to know if the infant is also infected. What is the best response by nurse DeAnna?
"It's too early to know; we have to wait until the infant has symptoms."
"Since the mother is so ill, it's likely the child is also infected with HIV."
"The ELISA test is positve, so the child is definitely infected."
"The PCR test is positive; this indicates HIV infection, which may or may not progress to AIDS."
A mother has received instructions about avoiding wheat and soy allergens. Which response by the mother would indicate that futher education is needed?
"I will not feed my child any breads made with wheat flour."
"I will allow may child to eat semolina pasta, the kind he loves."
"I will not feed my child shakes made with soy protein."
"I will read labels to be sure I am avoiding wheat and soy."
A young mother brings her new baby, diagnosed with congenital hypothyroidism, to the clinic so she can learn how to administer levothyroxine. Nurse Ashley should include which of the following instructions?
Crush the medication and place it in a full bottle of formula to disguise the taste
Administer the medication every other day
Use an oral dispenser syringe or nipple to give the crushed medication mixed with a small amount of formula
Tell the mother that the medication will not be needed after the age of 7
During a well-child examination which of the following comments made by the parent would indicate the possibility of a growth hormone deficiency?
"I have to buy my child new clothes every 2 to 3 months."
"I have to buy my child larger shirts than pants; otherwise, the sleeves are too short."
"My child wears out his clothes before he outgrows them."
"I can hand down my child's clothes to his younger brother."
Nurse Alina is caring for a 14-year-old boy with type I DM. He takes NPH insulin every morning at 7:30 a.m. Which assessment data will nurse Alina use to evaluate the therapeutic effectiveness of the medication?
Presence of signs and symptoms of hypoglycemia or hyperglycemia during the morning physical assessment
Blood glucose level at 1630
Appetite and food intake at lunch
Blood glucose level before breakfast
When monitoring the blood glucose level of a 12-year-old child with type 2 DM, your reading is 50 mg/dL. Which is the most appropriate action?
Encourage the child to get out of bed and increase activity
Take the child's vital signs
Ask the child about frequent urine output
Give the child 4 oz of orange juice
A 5-year-old has been diagnosed with Wilms tumor. What is the priority nursing intervention for this child?
Educate the parents about dialysis, as the kidney will be removed
Measure abdominal girth every shift
Avoid palpating the child's abdomen
Monitor BUN and creatinine every 4 hours
A child with leukemia has the following a.m. laboratory results: Hgb 8.0, Hct 24.2, WBC 8,000, platelets 150,000. What is the priority nursing assessment?
Determine intake and output
A child with leukemia received chemotherapy about 10 days ago. She presents today with a temperature of 100.4 degrees Fahrenheit, an absolute neutrophil count of 500, and mild bleeding of the gums. What is the priority nursing intervention?
Administer IV antibiotics as ordered
Provide vigorous oral care frequently with a firm toothbrush
Monitor pulse and blood pressure for changes
Administer packed red blood cell transfusion
A child with cancer is receiving chemotherapy, and his mother is concerned that the nausea and vomiting associated with chemotherapy are reducing his ability to eat and gain weight appropriately. What is the most appropriate nursing action?
Administer an antiemetic at the first hint of nausea
Offer the child's favorite foods to encourage him to eat
Start antiemetic drugs prior to the chemotherapy infusion
Maintain IV fluid infusion to avoid dehydration
Carrie is counseling a couple, one of whom is affected by neurofibromatosis, an autosomal dominant disorder. They want to know the risk of transmitting the disorder. Carrie should tell them that each different offspring has a:
One in four (25%) chance of getting the disease
One in eight (12.5%) chance of getting the disease
One in one (100%) chance of getting the disease
One in two (50%) chance of getting the disease
Nurse Katrina is working in a women's health clinic and determines that genetic counseling may be appropriate for a woman:
Who just had her first miscarriage at 10 weeks
Who is 30 years old and planning to conceive
Whose history reveals a close relative with fragile X syndrome
Who is 18 weeks pregnant and whose triple screen came back normal
A child born with a single transverse palmar crease, a short neck with excessive skin at the nape, a depressed nasal bridge, and cardiac defects is most likely to have which autosomal abnormality?
A mother brings her 4-day-old infant to the clinic with vomiting and poor feeding. The newborn was healthy at birth. Nurse Ratched should expect:
An inborn error of metabolism
Nurse Florence is caring for a child with Down syndrome. What should Florence's focus be?
Teaching hygiene skills to the child in order to increase self-esteem
Screening for anomalies and teaching about prevention of respiratory infection
Finding opportunities to increase socialization for the child and family
Expecting walking at age 1 year and toilet training completion at 2 years
Nurse Harmeet is caring for a child with Tuner syndrome admitted to the unit for treatment of a kidney infection. What characteristics associated with this syndrome may Harmeet expect to find upon assessment?
Low-set ears, cleft lip
Short stature, webbed neck
Gynecomastia, taller than average
Nurse Mary Breckinridge is caring for a child with ADHD. Which behavior would Mary NOT expect the child to display?
Moody, morose behavior with pouting
Interruption and inability to take turns
Forgetfulness and easy distractibility
Excessive motor activities and fidgeting
An adolescent girl who has been receiving treatment for anorexia nervosa has failed to gain weight over the past week despite eating all of her meals and snacks. What is the priority nursing intervention?
Increase the teen's daily caloric intake by at least 500 calories.
Ensure that the teen's entire fluid intake includes calories
Supervise the teen for 2 hours after all meals and snacks
Assess the teen's anxiety level to determine ned for medication
A 15-year-old girl has been making demands all day, exaggerating her every need. She is now crying, saying she has nothing to live for and threatening to kill herself. What is the priority nursing action?
Ignore her continued exaggerated and melodramatic behavior
Consult with the physician or nurse practitioner to increase her antidepressant dose
Leave the girl alone for a little while until she composes herself
Take the girl's suicidal threat seriously and provide close supervision
When trying to manage aggressive or impulsive behaviors in children or adolescents, what is the best nursing intervention?
Train the child to be assertive
Provide consistency and limit setting
Allow the child to negotiate the rules
Encourage the child to express feelings
Nurse Mary Ezra Mahoney is caring for an adolescent who says, "I'm sick of this. I wish I weren't alive anymore." What is the best response by Mary?
"I often feel sad and sick of things."
"Have you thought about hurting yourself?"
"Are you trying to escape your problems?"
"Do your parents know about this feeling?"
An unresponsive toddler is brought to the emergency department. Assessment reveals mottled skin color, respiratory rate of 10 breaths per minute, and a brachial pulse of 52 bpm. What is nurse Rosie's priority nursing action?
Prepare the defibrillator and draw up code medications
Provide 100% oxygen with a bag-valve-mask and start chest compressions
Start chest compressions and provide 100% oxygen via nonrebreather mask
Begin an IV fluid infusion and administer epinephrine IV
A 10-year-old child in respiratory distress requires intubation. Which sizes of tracheal tubes will nurse Brandee prepare?
9.5 mm and 10.0 mm
8.5 mm and 9.0 mm
6.0 mm and 6.5 mm
6.5 mm and 7.0 mm
A preschooler presents to the emergency department with a history of vomiting, diarrhea, and fever over the past few days. She is receiving 100% oxygen via nonrebreather mask. Vital signs are temperature 104.5 degrees Fahrenheit, pulse 144 bpm, respiratory rate 22 breaths per minute, and BP 70/50 mmHg. She is listless and difficult to arouse and has weak peripheral pulses and prolonged capillary refill. What nursing intervention by nurse Julisa takes priority?
Administering acetaminophen rectally for the high fever
Administering IV antibiotics for the infection
Preparing the child for tracheal intubation
Giving an IV bolus of normal saline 20 mL/kg
An 18-month-old child is brought to the emergency department via ambulance after an accidental ingestion. What is the priority nursing intervention for nurse Michelle?
Give oral syrup of ipecac
Insert a nasogastric tube
Start an IV line