HESI RN Pediatrics Exam V1, V2,V3 – (100 % Verified Q & A)(135 Answered Questions).

HESI RN Pediatrics Exam V1, V2, V3 100 % Verified Q & A 135 Answered Questions HESI RN Pediatrics V1,V2,V3 - 135 Answered Questions 1.The nurse is planning care for a 5 - month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instruction should the nurse provide this mother? • Dilute the child’s formula with equal parts of water • Offer 10% dextrose in water between most feeding • Give small amounts of baby food with each feeding • Thicken formula with cereal for each feeding 2.A 4-years-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching? • Muscular strength can be regained with physical exercise and therapy • Growth and development have been abnormal since birth • Respiratory dysfunction and aspiration are prime concerns at this stage of the disease • Lower legs become progressively weaker, causing a wedding, unsteady gait 3.In caring for an client with acute epiglottitis, which nursing action takes priority? • Obtain a stat CBC • Prepare for endotracheal intubation • Auscultate breath sounds • Apply ice packs to the neck 4.Which client requires immediate intervention by the nurse? • A toddler with chickenpox who is scratching • An adolescent with a migraine and photophobia • A child with cystic fibrosis who is constipated • A Child with acute renal failure and hyperkalemia 5.The nurse is conducting an admission assessment of an 11-months old infant with congestive heart failure who is scheduled repair of restenosis of coarctation of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower, with pathophysiologic mechanism support these findings? • The aortic semi lunar valve obstructs blood flow into the systemic circulation • An opening in the atrial septum causes a murmur due to a turbulent left to right shunt • The lumen of the aorta reduces the volume of flow to the lower extremities • The pulmonic valve prevents adequate blood volume into the pulmonary circulation 6.A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother? • Apply padding on the sharp corners of the furniture • Prevent the child from running inside the house • Give an 81 mg tablet of aspirin for pain relief • Use a soft toothbrush for frequent cleaning 7.The nurse is using the Stage Questionnaire (b) to assess a 24 - month-old child. What is the best intervention for the nurse to initiate after the assessment is completed? • Assess for changes in the vital signs • Review the child’s birth history • Provide the parents with a list of stimulating activities • Meet with a social worker to review the results 8.When caring for a child sickle cell disease, the nurse knows that the child will most likely exhibit which sign when experiencing a sickle cell crisis? • Decreased hemoglobin • Pain • Infection • Dehydration 9.The nurse is administering an oral medication to a reluctant preschool-age boy. Which intervention should the nurse implement? • Advise the parents that they will need to give the medication • Use straightforward approach with the child • Mix the medication in with the child’s favorite breakfast cereal • Offer to bring the medicine back later in the day 10.The nurse is planning care for a newborn infant scheduled for a cardiac catheterization. Which occurrence poses the greatest risk for this child? • Loss of pulse proximal to the entry side of the catheter • Allergic response to the plastics in the catheter used for catheterization • Acute hemorrhage from the entry site of the catheter after the procedure • Fever associated with nausea and vomiting after the procedure 11.The school nurse is presenting a seminar to parents about child safety that focuses on prevention of spinal cord injuries. What information is most important for the nurse include in the teaching plan? • Trampoline activities of school-aged children should be supervised by adults • Protective gear to prevent neck flexion should be worn during contact sports • Seat belt and car seat laws for use in motor vehicles should be reinforced • Monkey bars should be removed from school playgrounds to reduce falls 12.A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child’s oral temperature is 101.2 F (38 C). Which intervention should the nurse implement? • Provide parent education to prevent recurrence • Clearance purulent exudate from the affected ear canal • Apply a topical antibiotic to the preauricular area • Ask the mother if the child has had a runny nose 13.A mother is concerned that her 3-year-old son wants to play with female doll figures. The child is not interested in building blocks, trucks, or other typical “boy” toys. How should the nurse respond to the mother’s concern? • Letting male toddlers play with female-typed toys can have negative effects • Replacing female doll figures with male doll figures reinforces masculinity • Exploring different roles in imaginary play is typical at this age • Experimenting with different toys is an acceptable behavior 14.Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children? • Noting a marked weight gain without a gain in height on a growth chart • Performing head circumference measurements on infants under one year of age • Assessing for behavioral problems at home and school by interviewing the parents • Carefully recording the height and weight of children to detect inappropriate growth rates 15.The parents of a 4 week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain? • Level of infant’s distress after vomiting • Degree of forcefulness of vomiting episodes • Odor and texture associated with emesis • Position of the infant when vomiting occurs 16.A 4-month-old boy has an inguinal hernia that is visible when he cries, but it does not cause him discomfort. His parents ask if the hernia should be repaired now. The nurse’s response should be based on what information? • An inguinal hernia is treated as a surgical emergency • Surgical repair is planned after successful toilet training • An inguinal hernia is surgically repaired if persistent diarrhea occurs • Surgical correction is indicated if the hernia is incarcerated 17.A female of child - bearing age receives a rubella vaccination. She has two children at home, ages 13 months and 3 years. Which instruction is most important for the nurse to provide to this client? • Tell the mother to isolate the children for 3 days • Inquire if anyone in the family is allergic to eggs • Encourage the client to immunize the children • Assess family history for incidence of rubella 18.The teacher notifies the school nurse that a child’s nose is bleeding for no apparent reason. What action should the nurse implement first? • Tip the child’s head back to avoid swallowing blood • Pinch the nose using thumb and finger for 10 minutes • Insert a sterile cotton ball in the nares that is bleeding • Apply an ice compress to the child’s nose right away 19.A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 beast| minute. What action should the nurse implement? • Determined the pulse déficit • Calculate the safe dose range • Administer the scheduled dose • Review the serum digoxin level 20.The nurse is assisting the mother of child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? • High fat foods • Foods sweetened with aspartame • Wheat products • High calorie foods 21.During a routine physical exam, a male adolescent client tell the nurse, “ Sometimes, my mother gets angry because I want to be with my own friends”. What is the best initial response by the nurse? • Offer to discuss his concerns together with his mother • Ask about client’s response to his mother’s age • Determine if his friends are engaged unsafe behaviors • Offer reassurance that his mother’s concern is normal 22.Which response demonstrates that the mother of a young girl with a urinary tract infection (UTI) understands home care for the child? • I will give the antibiotics until she does not complain of burning anymore • I will bring her back to the doctor’s office for another urine test • I will make sure she wipes from back to front after she uses the bathroom • I will refill the prescription for antibiotics if her symptoms are skill present after taking these 23.The nurse is caring for a one-year-old boy who has type 1 diabetes mellitus (DM). His mother asks how will she recognize hypoglycemia in her infant who cannot tell her how he feels. Which information should the nurse provide? • The baby’s breath smell swells sweet when the sugar and blood ketone levels are high • Hypoglycemia in infants causes changes in behavior and cold clammy skin • Weight loss and a good appetite often occur when a baby’s glucose levels change • Excess urination and dry skin are common indicators of hypoglycemia 24.An 8 year-old child is admitted to the Emergency Department because of lower right quadrant pain, nausea, and vomiting. Which assessment of the abdomen should the nurse conduct after all other assessments are complete? • Percussion • Palpation • Inspection • Auscultation 25.An infant is admitted for surgery who has a Wilms’ tumor. What nursing intervention should the nurse implement during the preoperative period? • Administer pain medication based on the FACES pain scale • Give antiemetic medications to prevent nausea and vomiting • Include the prone position in the q2h turning schedule • Careful bathing and handling that avoids abdominal manipulation 26.A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding? • The TSH is high because of the low production of T4 by the thyroid • High thyroxine levels normally occur in breastfeeding infants • The thyroxine levels low because the TSH level is high • The thyroid gland does not produce normal levels of thyroxine for several weeks after birth 27.When administering indomethacin (Indocin) to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome? • Decreased cardiac murmur • Increased number of red blood cells • Decreased urinary output • Increased respiratory effort 28.A hospitalized child stiffens and stars to seize as the nurse enters the room. What actions should the nurse take? (Select all apply) • Turn client to the side if possible • Pad side rails with available pillows and blankets • Instruct the parents to leave the room • Notify the emergency response team • Monitor duration and progress of the seizure 29.A middle school male student was recently diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take? • Refer the child to the school counselor for educational testing • Seek the advice of the school principal regarding the child's learning needs • Ask the parents to become involved the child with his homework • Ask the parents to have the child seen by a clinical psychologist 30.An adolescent boy is hospitalized with full-thickness (third degreed) burns to both hands following a house fire. Three days after his admission to the burned unit, the nurse notes that teenager’s hands are becoming more edematous. Which intervention is most important for the nurse to include in this client’s plan care? • Record accurate intake and output • Ensure patient intravenous access • Assess radial pulses every 2 hours • Ensure that antibiotics are administered on time 31.A 10-year-old boy has been seen frequently by the nurse over the past three weeks after school begins in the fall. He reports headaches, stomach, and difficulty sleeping. What intervention should the nurse implement? • Conduct a complete neurological assessment • Ask the boy to describe a typical day at school • Counsel the parents to play more attention to the child • Compare the child’s vital signs over the past three weeks 32.A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents? • Permanent life-style changes need to be made to promote safety in the home • Consistent discipline is needed to help the child control the movements • Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged • The chorea or movements are temporary and will eventually disappear 33.A 3-year -old girl who has been blind since birth is hospitalized because of a compound fracture of the femur and is now in traction. Which intervention is best for the nurse to implement to address this child’s blindness? • Play a game where the child must identify unfamiliar sounds in the environment • Use a touch tour to allow the child to familiarize herself with the room layout • Request parents bring familiar objects as a stuffed animal from home • Perform the child’s self-care activities until the child is no longer in traction 34.The nurse has provided discharge teaching to the mother of a premature infant. Which statement by the mother would indicated that the understands the importance of making sure that her baby gets the monthly palivizumab (Synagis) injection? • Palivizumab will help with neurological and physical development • The medication will protect my baby from respiratory syncytial virus • Palivizumab will prevent the development retinopathy of premature • The monthly injections will baby’s lung mature 35.A 16 -year-old adolescent with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted medication port at the out-patient oncology clinic. What action should the nurse implement when the infusion is completed? • Initiate an infusion of normal saline • Administer ondansetron (Zofrant) • Flush the mediport with saline and a heparin solution • Obtain blood samples for RBCs, WBCs, and platelets 36.The nurse is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective? • Can lift head, but not chest when lying on abdomen • Has strong Moro and tonic neck reflexes • Laughs readily, turns from back to side • Keeps fists clenched, opens hands when grasping an object 37.A pre-school-age girl who has been taking oral ampicillin (Omnipen, Polycillin) for 3 days for a non-respiratory condition repeatedly tells the nurse that her throat hurts. The child has no evidence of dyspnea or urticaria. Which action should the nurse implement? • Explain gently that medication must be taken • Withhold the medication and notify the healthcare provider • Encourage eating ice chips after taking the medication • Assess apical heart rate and pulse points for irregularities 38.A 9-year-old boy is diagnosed with diabetes mellitus Type 1. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching this client about insulin injections? • Initiative • Industry • Autonomy • Identity 39.After receiving a single fluid bolus of 20 mg / kg of normal saline, a child’s heart rate is 140 beats/ minute, blood pressure is 70/50, and capillary refill is 6 seconds. The child is anxious and crying. Which intervention should the nurse implement first? • Encourage the caregiver to remain at bedside • Repeat the normal saline bolus as prescribed • Allow the child to assist with caregiving • Recommend age appropriate activities 40.The clinic nurse is assessing a 3-year -old child with sudden onset of irritability, thick muffled voice, and barking on inspiration. The child is febrile and leaning forward to breathe with tongue protruding, is drooling, and has suprasternal retractions. Which intervention should the nurse implement first? • Alert the emergency response team • Examine the child’s throat for edema • Collect a sputum specimen • Prepare the child for X-ray 41.The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider? • Audible heart murmur • Poor oral intake and suckling effort • Heart rate of 162 beasts/minute • Weight gain of 2.2 lbs (1kg) in las 48 hours 42.The nurse administers digoxin (Lanoxin) to a 9-month-old infant with an apical heart rate of 160 beats per minute. Which apical pulse rate indicates that therapeutic effect of the medication has been achieved? • 80 beats per minute • 180 beats per minute • 60 beats per minute • 120 beats per minute 43.Which toy is most appropriate for a 10 -year-old child with acute rheumatic fever who is on strict bed rest? • Play dough • Doctor kit • Punching bag • Checkers 44.A 12-year-old obese male comes to the clinic with his mother and a note from the school nurse for follow-up of Acanthosis Nigricans, a thickening and darkening of the skin. The child is concerned and anxious that he has a serious condition. How should the nurse respond? • Refer the child immediately to an endocrinologist for treatment • Ask the child and his mother what he was told about this condition • Encourage the child to modify his diet and begin an exercise • Assess the presence of type 2 diabetes mellitus in the family 45.A 10-year-old girl is diagnosed with inflammatory bowel disease (IBD). Her mother is concerned that she will experience developmental delays as the result of this disorder. How should the nurse respond? • She is at high risk for a number of different problems, including developmental delays • Scheduling a private tutor can help to prevent developmental delays • She will only experience developmental delays if weight loss cannot be controlled • Growth failure is a concern, but developmental delays are not likely to occur 46.A child is to receive vancomycin (Vancocin) 20 mg/kg IV one hour before a scheduled procedure. The child weight 77 pounds. How many mg of the medication should the nurse prepare to administer? (Enter numeric value only) 47.Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections? • Take frequent bubble baths • Monitor for changes in urinary odor • Check oral temperature daily • Perform intermittent catheterization 48.During her sports physical examination, 15-year -old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. What action should the nurse take? • Explain that she needs parental approval to receive contraceptives • Encourage the client to discuss her need for contraceptives with her parents • Counsel the client about the risks and benefits of using oral contraceptives • Tell the client how to receive a variety of oral contraceptives from the clinic 49.A child with acute laryngotracheobronchitis (croup) received epinephrine 2 hours ago in the emergency room, and is now being prepared for discharge to the home. The nurse should instruct the parents to take which action if the child’s uncontrolled coughing reoccurs? • Sit with the child in the bathroom with hot steam • Call for emergency transportation to hospital • Administer a dose of the prescribed cough medicine • Increase the fluid intake to liquefy the secretions 50.During a well baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have a prescription for Poly Vi Sol with fluoride. Though the infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain? • The infant’s current hemoglobin and hematocrit • Water source used with supplement feedings • Weight gain and type of formula taken daily • The newborn’s gestational age assessment 51.The mother of an 11 -year-old boy who has juvenile arthritis tells the nurse, “I really don’t want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting”. Which information is most important for the nurse to provide this mother? • The nurse use of hot baths can be used as an alternative for pain medication • The child should be encouraged to rest when he experiences pain • Encourage quiet activities such as watching television as a pain distracter • Giving pain medication around the clock helps control the pain 52.An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin intravenously. Which finding indicate to the nurse that the child is manifesting a therapeutic response? • Decreased periorbital edema • Increased periods of rest • Weight gain of 0.5 kg/day • Decreased urinary output 53.A 12-year-old boy with leukemia is being discharged from the hospital with a white blood cell (WBC) count of 4,000/mm. He is scheduled to receive antineoplastic chemotherapy as an outpatient. What instruction should the nurse include in this child’s discharge plan? • Avoid eating at buffets, smorgasbords, and salad bars • Spend time resting with family pets, bur only cats and dogs • Have all visitors wear protective masks when coming to the home • Swim weekly at the neighborhood pool for neuromuscular integrity 54.The nurse is assessing an 8-month-old who has a cough, axillary temperature of 100 F, and rhinorrhea. What information is most important for the nurse to obtain from this child’s mother? • Alcohol and drug intake of the mother • Labor and delivery history of the infant • Immunization status of the infant • Living conditions 55.Which client requires immediate intervention by the nurse? • A child with cystic fibrosis who is constipated • A toddler with chicken pox who is scratching • A child with acute renal failure and hyperkalemia • An adolescent with a migraine and photophobia 56.A 7-year-old male is referred to the school clinic because he fainted on the playground. His height is 3 feet, 7 inches (107.5 cm), he weighs 55 pounds ( 25 kg), and his body mass index (BMI) IS 20.9. Which assessment finding is most important for the nurse to address? • He consumed two bottles of water 30 minutes prior to fainting • Since age 3 he has experienced exercise induced asthma • Reports drinking 3 to 4 high calorie, carbonated beverages day • The child’s father has a history of fainting when exercising 57.The mother of 6-year-old girl is concerned about her child’s obesity. The child’s weight plots at the 75 percentile, and height at the 25 percentile. The child's body mass index (BMI) is at the 85 percentile for age and gender. Which interventions should the nurse implement? (Select all apply) • Explain that the child is likely to grow into weight • Determine the child’s usual physical activity pattern • Obtain the child’s 3 - day diet history based on the mother’s input • Inquire as to whether or not the school has a physical education • Tell the mother that girls hit their growth spurt before boys so eating 58.A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother? • Apply padding on the sharp corners of the furniture • Prevent the child from running inside the house • Give an 81 mg tablet of aspirin for pain relief • Use a soft bristle toothbrush for frequent cleaning 59.The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? • Place the infant in side-lying to facilitate the exam • Hold the penis and retract the foreskin gently • Cleanse the penis with an antiseptic-soaked pad • Place the infant in warm room and use a calm approach 60.An infant who has been diagnosed with a tracheoesophageal fistula (TEF). Which nursing intervention is indicated for this infant prior to surgical repair? • Provide frequent sips of liquid • Give isotonic enemas as prescribed • Maintain nothing by mouth status • Prepare the infant for a barium enema 61.An adolescent with non-Hodgkin's lymphoma (NHL) is complaining of sore mouth two days after begging chemotherapy. What activity should the nurse implement? • Encourage large meals during steroid and chemotherapy • Provide lemon glycerin swabs and dilute peroxide oral rises • Recommended fluids using citrus and drinking with a straw • Frequent use of saline oral rinses and soft sponge toothbrush 62.The nurse is performing a routine examination of a 6-month-old infant at community health clinic. Records indicate that the child weighed 3 kg at birth. The clinic uses lbs to describe weight. When assessing this child, approximately what weight, in lbs, should the nurse consider to be within normal range for this child? • 15 to 18 lb • 12 to 15 lb • 9 to 11.5 lb • 6 to 7.5 lb 63.When development a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the to eat a source of sugar if which symptom occurs? • Excessive thirst • Racing pulse • Profuse perspiration • Seeing spots 64.A breast feeding mother returns to work when her infant is 5 months old. She is having difficulty pumping enough milk to meet her infant’s dietary requirements. Which suggestion should the nurse provide to this mother? • Mix infant formula with breast milk • Supplement with an iron-rich formula • Introduce baby food for one meal daily • Offer a follow-up transitional formula 66.The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain? • Vigorous feeding and satiation • Hemiplegia • Fever • Hypotension and tachycardia 67.A child with possible Duchenne muscular dystrophy ( MD) undergoes an electromyogram (EMG). Following the procedure, the child’s parents tell the nurse that the child is complaining of sore muscle. How should the nurse respond? • Explain that muscle aches and pain are commonly experienced by children with this form of muscular dystrophy • Avise the parents that children with chronic diseases may seek attention by reporting pain or other unpleasant symptoms • Encourage the parents to motor the child’s body temperature for the next 24 hours and report a rinse above 101 F • Offer reassurance that muscle soreness following this procedures is temporary and does not indicate a problem 68.The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, and is now at 76 beats/minute; the previous reading 4 hours ago was 110 beats/minute. Which additional clinical finding should be reported immediately to the healthcare provider? • Respiratory heart rate of 25 breaths/minute • Urinary output of 20 ml/hour • Oxygen saturation of 94% • Blood pressure of 70/40 69.The health care provider prescribe epinephrine 0.01 mg/kg IM for a child with asthma who weighs 55 pounds. The available medication is labeled, 1 mg/ml. Based on the child's weight, how many ml should the nurse administer? (Enter numerical value only. If rounding, round to the nearest hundredth) 0.25 ml 70.After receiving a single fluid bolus of 20 mg/ kg of normal saline, a child’s heart rate is 140 beats/minute, blood pressure is 70/50, and refill is 6 seconds. The child is anxious and crying. Which intervention should the nurse implement first? • Repeat the normal saline bolus as prescribed • Allow the child to assist with caregiving • Recommended age appropriate activities • Encourage the caregiver to remain at bedside 71.The nurse should instruct the parent of an 8-year-old child who has sickle anemia to alert for which complaint from the child? • “I’m shorter than everyone else” • “I’m really hot and thirsty” • “I don’t want to eat any vegetables” • “I have to urinate every few hours” 72.During a routine clinic visit, the nurse determines that 5-year-old girl’s systolic blood pressure is greater than the 90th percentile. What action should the nurse implement next? • Take the blood pressure two more time during the visit and determine the average of the three readings • Measure the child’s blood pressure three times during the visit and determine the highest of the readings • Conduct a head-to-toe assessment and omit repeat blood pressure during the examination • Refer child to the healthcare provider and schedule evaluation of blood pressure in two weeks 73.A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. What action should the nurse implement first? • Initiate an IV site and begin infusing normal saline • Type and cross for possible transfusion • Monitor the child’s vital signs frequently • Apply ice pack and compression dressing to knee 74.What snack is best to provide a 6-year-old child on prescribed while receiving treatment for osteomyelitis? • Milk shape • Soup broth • Applesauce • Popsicle 75.A one - month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. What other finding should the nurse identify that are consistent with pyloric stenosis? • Perianal diaper rash from persistent diarrhea • Rooting, hunger, and irritability • Bite-stained emesis • An olive-shaped mass in the abdominal area 76.The nurse is evaluating a young child with atopic dermatitis. Which question should the nurse ask the parent while obtaining the child’s history? • Does the child have any nausea or vomiting? • Has the child displayed any symptoms of asthma or hay fever? • Can any particular stress be associated with onset of the rash? • What time of day does the rash appear on the body? 77.A female infant recently admitted with vomiting and diarrhea now weighs 10 kg. Her weigh at a previous well-baby visit was 11 kg. What is the percentage of body weight loss for this infant? • 10% • 5% • 9% • 4% 78.A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse note that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? • Auscultate the lungs for respiratory pneumonia • Draw blood to analyze for streptococcus infection • Change to latex - free gloves when handling infant • Apply zinc oxide to perineum with each diaper change 79.A 17-year-old male student with cystic fibrosis talks with the school nurse about his disease and wonders how it will affect getting married and having children. Which relevant information would the nurse include in this discussion? • He should undergo cystic fibrosis screening before having children • Impotence is a frequent problem for males with cystic fibrosis • If the father is a carrier, 50 % of the offspring will have cystic fibrosis • He is likely to have infertility problems and further evaluation 80.A child weighing 67 pounds receives a prescription for benztropine (Cogentin) 0.61 mg IV q 12 hours. This drug is available as 1 mg/ml ampoules. How many ml should the nurse administer? (Enter the numeric value only. If rounding is required, round to the nearest hundredth) • 0.61 ml/ dose 81.A 12-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is schedule. Which information should the nurse provide concerning to this procedure? • Explain that fluids cannot be taken for 8 hours before the procedure and 4 hours after the procedure • Tell the child to expend loud clicking during the procedure that may be annoying • Describe the side-lying, knee to the chest position that must be assumed during the procedure • Reassure the child that there will be no restrictions on activity after the procedure is completed 82.How should the nurse respond to the concerned parent of a 15-month-old who is not yet able to self-feed with a spoon? • Tell parent to guide the child’s hand using a spoon • Suggest using foods that can be eaten with fingers • Discuss possible causes for delay with self-feeding • Encourage longer mealtimes to practice eating with a spoon 83.A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? • Respiratory acidosis • Metabolic alkalosis • Respiratory alkalosis • Metabolic acidosis 84.When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement? • Assess skin for redness and signs of tissue breakdown • Change position every 2 hours • Cleanse pin site as prescribed • Monitor peripheral pulse and sensation in the leg 85.The healthcare provider prescribes antipyrine and benzocaine (Auralgan Otic), and anesthetic ear drop, for a two-year-old child with otitis media in the right ear. After positioning the child with the affect ear up, what action should the nurse take? • Cleanse the ear canal with saline • Put upward traction on the ear lobe • Pull pinna of the ear down and back • Gently massage in front of the ear 1-The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacked cast. Which assessment finding indicates to the nurse the client is developing cast syndrome? • Diminished pulses in the foot. • Musty, unpleasant odor to cast. • “Hot spot” felt on cast. • Abdominal distention. 2- The healthcare provider prescribes amoxicillin (Amoxil) 80mg PO every 8 hours for a child who weighs 25 pounds. The suspension is labeled Amoxil 125mg/5 ml. How many ml should the child receive in a 24-hour period? (Enter numeric value only. If rounding is required, round to the nearest tenth. 6- A child with Grave’s Disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response? • Increased weight gain. • Diminished fatigue. • Reduce headaches. • Decreased heart rate. 7- A male infant is admitted to the pediatric unit with pertussis and is exhibiting a “whooping-like cough.” The mother brings the infant to the nurse’s station to seek assistance. Which intervention should the nurse implement first? • Explain the need to maintain droplet precautions to prevent spread to others on the unit. • Ask the mother if the cool mist humidifier at the bedside is functioning and releasing mist. • Give the infant an oral dose of a prescribed antitussive and analgesic/antipyretic. • Cover the infant’s mouth and assist the mother to take the infant back to the room. 8- The nurse is assessing a 3-year-old boy who attends a daycare center. Following an upper respiratory tract infection, he developed acute otitis media. Which factor places this child at greatest risk for developing acute otitis media? • A child’s Eustachian tube is shorter and straighter than an adult’s Eustachian tube. • Attending a daycare center causes frequent exposure to other children with upper respiratory infections. • A child’s inner ear is more narrow than an adult’s and does not protect him from infection. • The immunity he received at birth from his mother is no longer effective. 9- When administering indomethacin (Indocin) to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome? • -A Increased number of red blood cells. • -B Decreased cardiac murmur. • -C Increased respiratory effort. • -D Decreased urinary output. 10- The nurse in the Emergency Center is triaging an 8-year-old boy who fell from a tree. The child is crying and complaining of pain in the left forearm. Which intervention should the nurse implement first? • Elevate the child’s left arm on a pillow. • Assess pain level using FACES scale. • Apply a cold pack to his left forearm. • Check capillary refill of the nail beds. 11- Several children at a day camp return from playing in a tick-infested field. What action should the camp nurse take first? • Observe the children’s skin for attached ticks. • Ask the children if they were using tick repellant. • Encourage the children to lie down and rest quietly. • Assess the children for the presence of a bull’s eye rash. 12- A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother? (Select all that apply.) • Drinking soda is related to childhood obesity. • Toddlers should be drinking from a cup by age 2. • Dental caries are associated with drinking soda. • A 2-year-old should be speaking in 2 word phrases. • Toddlers should be sleeping 10 hours a night. 14- The nurse is assessing a 2-year-old child. What behavior indicates that the child’s language development is within normal limits? • Is capable of making a three-word sentence. • Half of child’s speech is understandable • Can count five blocks. • Is able to name four color. 15- A 2-year-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her respiratory rate and heart rate have increased during the last hour. Which intervention should the nurse implement? • Administer a PRN analgesic prescription. • Notify the healthcare provider of these finding. • Record the finding in the child’s record. • Wrap the infant tightly and rock in rocking chair. 16- A child who is preparing to enter the first grade has recurring atopic dermatitis (eczema) and is brought to the clinic because of a recent exacerbation. Which suggestion should the nurse provide this child’s parent? • Ensure that the child’s lunch at school is a hypoallergic diet. • Encourage the child to wear cotton gloves while at school. • Keep the child at home during exacerbations of the dermatitis. • To prevent the scorn of classmate, consider home schooling. 18- The mother of a toddler reports to the nurse working in the pediatric clinic that her child has had a fever and sore throat for the past two days. The nurse observes several swollen red spots in the child’s body, a few of which are fluid filled blisters. What action should the nurse implement? • Obtain fluid culture from blisters. • Cover draining vesicles with a dressing. • Implement transmission precautions. • Administer a fever reducing salicylate. 19- A male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother’s bottle of digoxin (Lanoxin). What prescription should the nursed implement first? • Obtain a 12-lead electrocardiogram. • Give IV digoxin immune fab (Digibind) • Prepare for gastric lavage. • Administer activated charcoal orally. 22-When assessing a newborn, the nurse includes assessment for early signs of congenital hip dysplasia. Which finding is an indication of this condition? • -A Depressed dance reflex. • -B Limited adduction of the affected leg. • -C Asymmetry of the gluteal folds. • -D Shortening of the leg on the unaffected side. 23- An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin (Levaquin) 500 mg orally once daily and metronidazole (Flagyl) 500 mg twice daily. She asks the nurse, “Why do I have to be in the hospital? Why can’t I get my treatment at home?” Which purpose should the nurse provide that supports and effective outcome? • Detection of early symptoms of Jarisch-Herxheimer reaction. • Administration of a supervised parenteral antibiotic protocol. • Implementation of contact precautions to preventions to prevent spread of infection. • Collection of serial anaerobic cultures of vaginal discharge. 24- During the admission procedure of a 6-year-old, the child states, “I’m going to have an operation.” Which response is best for the nurse to provide to this child? • “We’re going to do everything we can to take very good care of you.” • “Tell me what an operation is.” • “Are you scared?” • “I’m glad your mother told you why you were coming to the hospital.” 25- A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill time of 2 seconds. What information should the nurse discuss with the mother? • Lay infant flat on back for naps. • Keep infant isolated from others. • Limit the amount of oral intake. • Encourage the infant to play. 26- A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child’s mother tells the nurse that she uses this medication to open her son’s airway when he is having trouble breathing. What is the nurse’s best response? • Recommend that the mother bring the child in for immediate. • Assure the mother that she is using the medication correctly. • Advise the mother that over-use of the drug may cause chronic. • Confirm that the medication helps to reduce airway inflammation. 27- In developing a plan of care for a child with bacterial meningitis, which intervention should the nurse plan to implement? • Maintain strict insolation after identification of the causative agent. • Maintain Trendelenburg’s position to decrease intracranial pressure. • Administer large volumes of intravenous fluids to minimize nephrotoxic effects of antibiotics. • Administer antibiotic therapy until the cerebrospinal fluid finding are negative. 29- The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take? • Document the finding. • Auscultate bowel sounds. • Palpate scrotum for testicular descent. • Assess for bladder distention. 32- A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family? • The infant’s formula has been changed twice. • The diapers area shows severe skin breakdown. • The mother state the baby is irritable during feedings. • The mother is a single parent and lives with her parents. 33- Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care? • A Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen). • Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N). • Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin R). • Demonstrate to parents how to program an insulin pen for daily glucose regulation. 34- The mother of a 2-year-old boy consults the nurse about her son’s increased temper tantrums. The mother states, “Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?” Which recommendation is best for the nurse to provide this mother? • -A Immediately put him in time-out.” • -Walk away from him and ignore the behavior. • -C Paddle him gently as soon as the behavior is initiated. • -D Quietly remind him that others are watching him. 35- The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, and is now at 76 beats/minute; the previous reading 4 hours ago was 110 beats/minute. Which additional clinical finding should be reported immediately to the healthcare provider? • Blood pressure of 70/40. • Respiratory rate of 25 breaths/minute. • Oxygen saturation of 94%. • Urine output of 20ml/hours. 36- A mother brings her 2-month-old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle is not descended into the scrotum but the left is palpable. Which action should the nurse take? • Address possible concerns about the child’s future fertility. • Ask if the right testis has been seen in the scrotum before. • Schedule an IV pyelogram to validate presence of testicle. • Prepare to obtain a catheterized urine specimen for culture. 37- A 6-month-old, diagnosed with short bowel syndrome, began enteral feedings yesterday. To maintain normal growth and development of the child during this period, what action should the nurse include in the infant’s plan of care? • Speak to the healthcare provider about instituting physical therapy. • Ensure placement of the nasogastric tube with an abdominal x-ray. • Use sterile technique during feedings. • Give the infant a pacifier during feeding. 38- Which nursing problem has the highest priority when providing preoperative care for an infant born with bladder atrophy? • Altered urinary elimination related to exposure of bladder. • Risk for impaired parenting related to appearance of infant. • Knowledge deficit related to caring for the infant. • Risk for infection related to impaired skin integrity. 39- The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and been walking without assistance for one month. Which technique should the nurse select for administration? • A Administer the injection into the middle of the lateral aspect of the thigh. • Use a needle length of ½ inch (1.25cm) to avoid deep tissue damage. • Divide the gluteal area into quarters and give IM into the upper outer quadrant. • Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process. 40- A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation? • 5-month-old with use of whole hand grasp. • 1 ½-year-old attempting to scribble on paper. • 3-year-old preferring to walk on the tip toes. • 3 ½-month-old with diminished Moro reflex. 43- The nurse is using the Ages and Stages Questionnaire (ASQ) to assess a 24-month-old. What is the best intervention for the nurse to initiate after the assessment is completed? • -A Review the child’s birth history. • -B Provide the parents with a list of stimulating activities. • -C Meet with a social worker to review the results. • -D Assess for changes in the vital signs. 46- The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? • Diuresis during the night. • A sore throat last week. • Back pain for a few days. • A history of hypertension. 54- An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? Reduce peripheral tissue hypoxia and nailbed clubbing. Stop the flow unoxygenated blood into systemic circulation. Increase the flow of unoxygenated blood to the lungs. Prevent the return of oxygenated blood the lungs. 55- In developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first? • Provide the child with positive feedback. • Encourage other children on the unit to describe the token system. • Determine what activities, foods, and toys the child enjoys. • Evaluate the child’s previous reactions to punishment. An adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up visit. Which information is most important for the nurse to obtain? a. Missed medication doses b. A 24-hour dietary recall c. Barrier contraceptive use d. Ingestion of illicit drugs VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV 1. The nurse is caring for a 3-year old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? • Blood pressure trend is downward and pulse is rapid and irregular • Right foot is cool to the touch and appears pale and blanched. • Pulse distal to the femoral artery is weaker on the left foot than right foot. • The pressure dressing at right femoral area is moist and oozing blood. 2. Following a motor vehicle collision, a 3-year old girl has a Spica cast applied. Which toy is best for the nurse for this 3-year-old child? • Duck that squeaks. • Fashion doll and clothes • Set of cloth and hand puppets • Hand held video game. 3. An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which action should the nurse implement first? • Administer morphine sulphate. • Start IV fluids. • Place the infant in a knee-chest position • Provide 100% oxygen by face mask. 4. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul’s respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? • Metabolic alkalosis. • Respiratory acidosis. • Respiratory alkalosis. • Metabolic acidosis 5. 7 years old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? • Gastric output of 100 mL in the last 8 hours. • Shift intake of 640 mL IV fluids plus 30 mL PO ice chips. • Serum potassium of 3.0 mg/dL. • Serum pH of 7.45. 6. The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective? • Creamed corn • Pancakes. • Rye crackers. • Cooked oatmeal. 7. During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? • Separation anxiety. • Associative play. • Object apprehension. • Object permanence .8. The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? • Measure the infant’s head-to-toe length. • Palpate the anterior fontanel for tension and bulging • Observe the infant for sunken eyes. • Plot the measurement on the infant’s growth chart. 9. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-old sibling are at the child’s bedside. Which instruction best supports family? • While waiting for the healthcare provider, only one visitor may stay with the child. • All of you should leave while the healthcare provider sutures the child’s forehead. • It is best if the sibling goes to the waiting room until the suturing is completed. • Please decide who will stay when the healthcare provider begins suturing 11. While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors? • Children need help in developing social skills. • This age child fears loss of self-control. • They provide the child with a sense of security • Children must to learn to deal with authority. 12. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? • Repair should be done by one month to prevent bladder infection. • To form a proper urethra repair, it should be done after sexual maturity. • Repairs typically should be done before the child is potty trained. • Delaying the repair until school age reduces castration fears. 13. Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary consideration related to the disease? • Milkshake. • Iced tea. • Diet cola. • Lemonade. 14. The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? • Tachycardia • Bradycardia. • Dry mucous membrane. • Increased skin turgor. 15. While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take? • Identify the antibiotic used to treat the pneumonia. • Inquire about the use of alternative methods of treatment • Ask the parents if the child has been in a recent accident. • Report suspected child abuse to the authorities. 16. A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement? • Obtain specimen for blood cultures • Assess the CBC. • Monitor the oral temperature every hour. • Administer acetaminophen as prescribed. 17. A child who weighs 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many mgs should the nurse administer to the child for each dose? 1875mg 18. The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement? • Instruct the parents that the infant needs to be NPO. • Notify the healthcare provider of the passage of brown stool. • Obtain a stool specimen for laboratory analysis. • Ask the parents about recent changes in the infant’s diet. 19. The mother of a 4-month old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide? • At diaper change generously powder the baby’s diaper area with talcum powder to promote dryness. • Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown. • Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change. • Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely. 20. Which statement by a school aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease? • I’ll cover my mouth with a wet cloth if there’s too much dust blowing. • Cuts and scrapes need to be washed out and covered right away. • I’m not going to swim where the water is standing still or feels too hot. • I have to wear long sleeves and pants when we’re hiking around the pond. 22. The HR for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, now it’s 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider? • Oxygen saturation 94%. • RR of 25 breaths/minute. • Urine output 20 mL/hr. • BP 70/40. 24. the parents of a 3 y/o boy who has Duchenne muscular dystrophy (DMD) ask “how can our son have this disease? We are wondering if we should have any more children” What information should the nurse provide these parents? • This is an inherited X-linked recessive disorder, which primarily affects male children in the family • The male infant had a viral infection that went unnoticed and untreated, so muscle damage was incurred • The XXXX muscle groups of males can be impacted by a lack of the protein dystrophy in the mother • Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles 25. The nurse finds a 6 month old infant unresponsive and calls for help. After opening the airway and finding that the infant is still no breathing. Which action should the nurse take? • Palpate femoral pulse and check for regularity • Deliver cycles of 30 chest compressions and 2 breaths • Give two breaths that makes the chest rise • Feel the carotid pulse and check for adequate breathing 26. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first? • Remove the child who has HIV from the foster home • Report the exposure of the child with HIV to the health department • Place the child who has HIV in reverse isolation • Review the immunization documentation of the child who has HIV 27. A 16 y/o female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is “beating a mile per minute” Which information is most important for the nurse to obtain? • When she last took the antihistamine • When her last Asthma attack occurred • Duration of most asthmas attacks • How often the MDI is used daily 28. The nurse is assessing a child for neurological soft signs, which finding is most likely demonstrated in the child’s behavior? • Inability to move tongue in a direction • Presence of vertigo • Poor coordination and sense of position • Loss of visual acuity 29. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture? • Metabolic alkalosis • Respiratory acidosis • Metabolic acidosis • Respiratory Alkalosis 30. A 4 month-old girl is brought to the clinic by her mother because she has had a cold for 2 o 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? • Bilateral bronchial breath sounds • Diaphragmatic respiration • A resting respiratory rate of 35 breathe per minute • flaring of the nares 31. a two-year-old boy begins to cry when the mother starts to leave. What is the nurse’s best response in this situation? • Let me read this book to you • Two years old usually stop crying the minute the parent leaves • Now be a big boy. Mommy will be back soon • Let’s wave bye-bye to mommy 33. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis “altered nutrition, less those body requirements related to anorexia, nausea and vomiting” is identified. Which intervention the nurse included in this child plan of care? • Encourage a variety of large portions of food at every meal • Allow the child to eat any food desired and tolerated • Recommended eating the food as sibling eat at home • Restrict food brought form fast food restaurants 34. a 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has a35% of personal best peak expiratory flow rate (PEFR) based on these finding, actions should the nurse take first? • Administer a prescribed bronchodilator • Encourage the child to cough and deep breath • Report findings to the heath care provider • determine what triggers precipitated this attack 35. The nurse plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weighs 55 pounds. Digoxin is available as elixir of 50 mcg/ml. How many ml of the digoxin elixir should the nurse administer to this child? • 5 ml 36. the nurse observes a mother giving her 11 month-old ferrous sulfate, followed by two ounces of orange juice. What should the nurse do next? • suggest placing the iron drops in the orange juice and feed the infant • Tell the mother to follow the iron drops with formula instead of orange juice • instruct the mother to feed the infant nothing in the next 30 minutes after the iron • Give positive feedback about the way she administered the sulfate 37. Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis • encourage fluid intake • promote complete bed rest • weight the child daily • Administer vitamin supplements 38. During a well-baby visit the parents explain that a soft bulge appears in the groin of their 4-month old son when he cries or strain stooling. The infant is schedule for surgical repair of the inguinal; hernia in two weeks. The parent should be instructed to take which measure if the hernia becomes incarcerated prior to the surgery? • Use rectal thermometer for straining on stool • Gently manipulate the hernia for reduction • Offer oral electrolyte fluids for comfort • Give acetaminophen or aspirin for crying 39. A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission he begins to have a grand mal seizure. Which action should the nurse take? • Obtain assistance in holding him to prevent injury • Observe him carefully • Call a CODE • Place a padded tongue blade between the teeth 40. The mother of a 9-month old who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first b-day party of a friend’s child the following day. What response should the nurse provide this mother? • The child will no longer be contagious, no need to take any further precaution • Make sure there are not children under the age of 6 months around the infected child • The child can be around other children but should wear mask at all times • Do not expose other children to RSV. It is very contagious even without direct contact 41. When screening a 5-year-old for strabismus, what action should the nurse take • Have the child identify colored patterns on polychromatic cards • Direct the child through the six cardinal position of glaze • Inspect the child for the setting sun sign • Observe the child for blank, sunken eyes 42. The nurse is assessing a 6-month old infant. Which response requires further evaluation by the nurse? •