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1. To help prepare a 4 y/o for postoperative abdominal surgery care, a nurse
should take which of these measures?
· Teaching the child how to contract and relax the abdominal muscles
· Having the child wear a chest restraint whenever he/she is in bed
· Practicing deep-breathing exercises with the child
· Telling the child to lie either on the back or on the side until allowed out of
bed: The nurse should practice deep breathing exercises with the child; this will help postoperatively because it will
help expand the lungs, decreasing the chance of postoperative respiratory complications.
2. A 12 y/o girl who has type 1 DM receives 5 units regular insulin and 20 units
isophane insulin subcutaneously at 7am. She eats her breakfast at 7:30am and
goes to school. At 10:30 am she reports feeling shaky and sweaty. A school
nurse should make which of these interpretations of this information?
· The Humulin-R insulin is peaking at this time
· The girl needs additional Humulin-R insulin
· The NPH insulin is peaking at this time
· The girl needs additional NPH insulin: The nurse should interpret that the regular insulin
(Humulin-R) is peaking at this time. Humulin-R has an onset of action within 30 minutes of injection, peaks at 1-3
hours, and has effects that last 6-8 hours. NPH has an onset of about 2 hours following injection, peaks at 4-12 hours
after injection, and a duration of 18-26 hours after injection
3. An 18 month old child has been placed on Bryant traction. The traction has
been properly applied if a nurse observes that
· Both legs are at a 35 degree angle
· 10-pound weights are in place
· The ropes are slack
· Both buttock are off the bed: Bryant's traction is used for children with fractured femurs and both legs
are suspended at 90 degree angles to the trunk of the body and the weight of the body pulls the bone fragments of
the fractures leg into alignment. If both buttocks are off the bed, then the traction is properly applied.
4. Which of these measures should a nurse plan for a 3 ½ y/o child whose
scrotum is very edematous?: · Applying a lanolin-based lotion to his scrotum
· Instructing him to avoid touching his scrotum when voiding
· Supporting his scrotum on a soft pad
· Placing cold compresses on his scrotum
, NACE: care of the child
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The nurse should plan on supporting his scrotum on a soft pad. This will help decrease the pressure and the weight
pulling down on the scrotum.
5. While an 18-month-old boy is in a mist tent, which of these toys would be
most appropriate?
· Crayons and a coloring book
· A wooden telephone
· Colored balloons
· A mobile: A wooden telephone would be the most appropriate under a mist tent.
6. The purpose of giving a low-phenylalanine formula to an infant who has
phenylketonuria (PKU) is to
· Prevent the accumulation of phenylalanine in the blood
· Prevent the secretion of the enzyme phenylalanine hydroxylase
· Promote the conversion of phenylalanine to tyrosine
· Promote the excretion of phenylpyruvic acid in the urine: Preventing the accumulation
of phenylalanine in the blood is the purpose of giving the infant a low-phenylalanine formula.
7. A 12 month old child is admitted to the hospital for open heart surgery for
repair of the ventricular septal defect. When preparing this client for surgery,
which intervention would be most appropriate?
· Allow the child's mother to stay in the preoperative area until the child is
sedated prior to surgery
· Have the child play with suture material to what will be used on the child's skin
incision
· Show the child the surgical room and all the equipment
· Explain to the child the functioning of the cardiopulmonary bypass machine to
be used during surgery: Toddlers fear abandonment; as a result, separation from family can be extremely
stressful. Their ability to comprehend a new environment or unfamiliar materials or machines is limited and would not
be appropriate for this child.
8. On a routine home visit, a visiting nurse learns that a 3 y/ child who has short
bowel syndrome has had diarrhea for the past 12 hours. An assessment reveals
that the child is mildly dehydrated and has no other abnormal findings. Which
of these foods should a nurse suggest that the mother give the child?
· Orange juice