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a nurse is planning care for a child who has severe diarrhea. which of the
following actions is the nurse priority?
ANS:<< Assess fluid balance
A nurse is reinforcing reaching with a parent of a 1 month old infant who is to
undergo the initial surgery to treat Hirschsprung's disease (a ganglionic
megacolon, part of the colon isn't connected to the nerves or not functioning, so
there will be an increase size of the colon and stool gets stuck in there). Which
of the following statements should indicate to the nurse that the parent
understanding the goal of surgery?
ANS:<< "I'm glad that the ostomy is only temporary " (1st there going to cut the
nonfunctioning of the colon, and then apply temporary colostomy, after a couple
of months they will suture it together)
A nurse is caring for a toddler who's parent states that the child has a mass in
his abdominal area and his urine is a pink color. Which of the following actions is
the nurse's priority?
ANS:<< Instruct the parent to avoid pressing on the abdominal area
A nurse is caring for a child who has acute glomerulonephritis. Which of the
following actions is the nurse's priority?
ANS:<< Check the Childs weight daily
A nurse is caring for a child who has a suspected diagnosis of bacterial
meningitis. Which of the following is the nurse's priority?
ANS:<< Administer antibiotics when available
,A nurse is collecting data from an adolescent. Which of the following represents
the greatest risk for suicide?
ANS:<< Active psychiatric disorder (Mark, mental problems, patients mind is
unstable)
A nurse is collecting data from an infant who has otitis media (middle ear
infection). The nurse should expect which of the following findings?
ANS:<< Tugging on the affected ear lobe
A nurse is caring for an infant who is 1 day postoperative following surgical
repair of a cleft lip. Which of the following actions should the nurse take?
ANS:<< Apply an antibiotic ointment to the suture site
A nurse is reinforcing discharge instructions with a parent of a child who has
cystic fibrosis. Which of the following statements by the parent indicates an
understanding of the teaching?
ANS:<< "I will make sure my child washes her hands before eating"
A nurse working at a clinic speaks on the telephone with a parent of a 2-
monthold infant. The parent tells the nurse that the infant has projectile vomiting
followed by hunger after meals. Which of the following response by the nurse is
appropriate?
ANS:<< "Bring your infant into the clinic today to be seen"
A nurse is caring for a 4 year old child who is 2 days postoperative following the
insertion of a ventriculoperitoneal shunt. Which of the following findings should
the nurse identify as the priority . (causes icp hydrocephalus)
ANS:<< lethargy (high pitched cry, respiratory changes, bradycardia, wide
pulse pressure, irritability
a nurse is caring for a child following an open reduction and internal fixation of a
fractured femur and application of a cast. The cast has a window cut in it for
viewing of the incision. Which of the following actions should the nurse take
first?
ANS:<< Perform neurovascular checks of the affected extremity (check for
infection, color, capillary refill, redness)
A nurse is an urgent care clinic is assisting with the care of a toddler who
ingested 30 tablets of aspirin. Which of the following substances should the
nurse administer to the toddler?
,ANS:<< Activated charcoal (can work with toxin, poison. Given through ng tube
absorbs toxins)
A nurse is caring for a 3 year old client who has persistent otitis media. To help
identify contributing factors, the nurse should ask the parents which of the
following questions?
ANS:<< Does anyone smoke in the same house as your daughter? (smoking can
cause irritation, cause mucus in respiratory and causes otitis media?) (otitis
media is purulent color)
A nurse is collecting data from a 2 year old toddler who has AIDS. The nurse
should inspect inside the toddler mouth for which of the following opportunistic
infections (fungus infections is usually opportunistic infections)?
ANS:<< Candidiasis (also called oral thrush)
A nurse is caring for a 4 year old child who has dehydration. Which of the
following findings should the nurse identify as the priority?
ANS:<< Potassium 2.5 mEq/L
A nurse is caring for a child who Is postoperative following the insertion of a
ventriculorperitoneal shunt. The nurse should place the child in which of the
following positions?
ANS:<< On the nonoperative side
A nurse is caring for an infant who is dehydrated and requires IV therapy. The
nurse should monitor the infant response to therapy by performing which of the
following actions?
ANS:<< weighing the infants at the same time everyday
A nurse is caring for a preschool age child who has croup. Which of the
following findings should the nurse report to the provider?
ANS:<< Drooling (that could mean it can mean there's an epiglottitis causes
obstruction of the airway)
A nurse is collecting data from an infant who has hypertrophic pyloric stenosis.
Which of the following findings should the nurse expect?
ANS:<< Projectile vomiting
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which
of the following instructions should the nurse give the child for this examination?
, ANS:<< Bend forward from the waist with your head and arms downward
A nurse is collecting data from an infact. Which of the following sites is the most
reliable location to check the infats pulse ?
ANS:<< Apical
A nurse is reinforcing teaching with a parent of a child who has eczema. Which
of th following instructions should the nurse include in the teaching
ANS:<< Apply a cool wet compress to the affected area
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the
following actions should the nurse take?
ANS:<< Maintain night splints to the affected joint
A nurse is reinforcing teaching with a parent of an 8-year-old child who has a
fracture of the epiphyseal plate. Which of the following statements should the
nurse include in the teaching.
ANS:<< Normal bone growth can be affected by the fracture
A nurse is collecting data from an 8 month old infant who has increased
intracranial pressure (ICP) which of the following manifestations should the
nurse expect?
ANS:<< Bulging fontane
A nurse is caring for a school age child who has a fracture to the right femur.
Which of the following findings is the nurse priority?
ANS:<< tingling in the right foot
A nurse is caring for a child who has atopic dermatitis. Which of the following
findings should the nurse expect?
ANS:<< Rash with thick skin
A nurse is assisting with the care of a school age child who has respiratory
failure due to pneumonia. Which of the following positons should the nurse
encourage to allow maximal lung expansions?
ANS:<< Upright (orthopnic positon, semi fowler, high fowler)
A nurse in a provider's office is reinforcing teaching with a parent of a school
age child who has pediculosis capitis. Which of the following instructions should
the nurse include in the teaching?