A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following
parent statements indicated an understanding of the teaching? Correct Answers: "I will place a
screen in front of the fireplace.
A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease.
Which of the following foods should the nurse recommend including in the child's diet? Correct
Answers: White rice
A nurse in a clinic is collecting data from an adolescent who has received all recommended
immunizations through the age of 6 years. Which of the following immunizations should the nurse
paln to administer? Correct Answers: Tetanus, diptheria toxoids, and acellular pertussis (Tdap)
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of
the following areas should the nurse observe when monitoring for manifestations of splenic
sequestration? Correct Answers: Box B
(Anatomic position left side)
B is correct. The nurse should observe the location over the infant's spleen when monitoring for
manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to
pooling of sickled cells in the blood.
A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea.
Which of the following findings should the nurse identify as a risk for this disorder? (Select all) Correct
Answers: Hypothyroidism
Cannabis
Oral contraceptive
Emotional stress
A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following
actions should the nurse take? Correct Answers: Have a suction canister and tubing available in the
room.
A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM
antibiotic to a child 5 min ago. Which of the following manisfestations should the nurse expect to
observe first? Correct Answers: Hives
A nurse is contributing to the plan of care for an adolescent who has human immunodeficiency virus
(HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the
plan of care? Correct Answers: Inform the client regarding routes of transmission.
A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse
should identify which of the following as an indication that the preschooler experienced an allergic
reaction to the contrast dye? Correct Answers: Urticaria
, A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1
diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
Correct Answers: "Put your child's finger under warm, running water prior to collecting blood."
A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for
surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs,
they cannot receive a blood transfusion. Which of the following responses should the nurse make?
Correct Answers: "Let's discuss the possible need for transfusion with your parents."
A nurse is reinforcing teaching with the guardians of a school-age childwho has hearing loss. Which
of the following techniques should the nurse recommend to facilitate communication with the child?
Correct Answers: Use facial expressions when speaking.
A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of
the following findings indicated the infant's status is improving? Correct Answers: Sodium level 145
mEq/L
A nurse has just received change-of-shift for four children in a pediatric unit. Which of the following
children should the nurse collect data from the first? Correct Answers: A child who has a fever and
nuchal rigidity.
A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the
following should the nurse recognize as an early manifestation of increased intracranial pressure?
Correct Answers: Increased irritability
A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following
laboratory values should the nurse report to the provider? Correct Answers: Hgb 6 g/dL
A nurse is collecting data from an infant who has severe dehydration. Which of the following findings
should the nurse expect? Correct Answers: Weight loss of 10%
A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following
responses by the child is an indication of a transfusion reaction? Correct Answers: "I am cold. Can I
have an extra blanket?"
A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the
following actions should the nurse take? Correct Answers: Report the suspected abuse to the
authorities
A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a
vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to
include in the plan? Correct Answers: Promote oxygen utilization.
A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should
identify that which of the following findings puts the client at risk for nutritional deficits? Correct
Answers: The client fasts twice a week to manage dietary intake.
A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a
nasogastric tube. Which of the following actions should the nurse take? Correct Answers: Confirm
that the pH of the stomach contents is 5 or less.