Test Bank for Davis Advantage for Pediatric Nursing: Critical
Components of Nursing Care, 3rd Edition by Kathryn Rudd
9781719645706 , All Chapters with Answers and Rationals
A nurse is caring for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH).
Which laboratory test would the nurse be least likely to obtain?
A) Urine specific gravity.
B) Blood glucose.
C) Serum sodium.
D) Urine osmolality. - ANSWER: B) Blood Glucose
Obtaining a blood glucose level is not expected for a child diagnosed with SIADH since the priority
measures involve blood and urine osmolality. Blood glucose is a likely laboratory test in a child with
diabetes insipidus.
A physician prescribes digoxin (Lanoxin) for a toddler with congestive heart failure (CHF). Before
administering the medication, it is most important for the nurse to:
A) First obtain an apical heart rate.
B) Determine the serum potassium.
C) Review the child's admission electrocardiogram (ECG).
D) Mix the medication with a pleasant-tasting food. - ANSWER: A) First obtain an apical heart rate
Rationale - Apical heart rate must be obtained by the nurse prior to the administration of digoxin
(Lanoxin) to a child. Unless otherwise prescribed, the medication is typically withheld for a heart rate
below 90 to 110 bpm in young children
A nurse prepares to administer spironolactone (Aldactone) to an infant with congenital heart disease.
The nurse understands that the main purpose of this medication is to:
A) Preserve the patent ductus arteriosus.
B) Cause vasodilation of the blood vessels.
C) Prevent the secretion of potassium.
D) Block aldosterone, which leads to diuresis. - ANSWER: D) Block aldosterone, which leads to
diuresis.
Rationale - Spironolactone (Aldactone) is a diuretic that blocks aldosterone. Use of this medication is
common among children with congenital heart disease for the prevention and treatment of
congestive heart failure.
Which symptom(s), if present in a child, should a nurse recognize as being characteristic of Kawasaki
disease? Select all that apply.
A) Strawberry tongue.
B) High fever.
C) Irritability.
D) Cough.
E) Desquamation of the extremities.
F) Elevated ESR. - ANSWER: A) Strawberry tongue.
B) High fever.
C) Irritability.
E) Desquamation of the extremities.
F) Elevated ESR.
,Rationale - Strawberry tongue is a symptom of Kawasaki disease (mucocutaneous lymph node
syndrome), occur- ring as the skin of the tongue sloughs off, leaving a bright red tongue with white
spots. A symptom of Kawasaki disease is high fever lasting more than 5 days. Irritability is a symptom
of Kawasaki disease.
The child with Kawasaki disease may experience peeling of the hands (on palms and fingertips) and
feet (on soles and tips of toes) following the initial inflammatory rash on these areas.
An elevated erythrocyte sedimentation rate (ESR) is a symptom of Kawasaki disease. Elevated ESR is
indicative of an inflammatory process, which would include Kawasaki disease.
Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome
who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
A) Call physician for oxygen saturations below 85%.
B) Daily weights.
C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
D) Strict I&O.
E) Enfamil formula ad lib. - ANSWER: A) Call physician for oxygen saturations below 85%.
C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
E) Enfamil formula ad lib.
Rationale - The nurse should question an order that requires the nurse to call the physician for an
oxygen saturation that is appropriate for an infant waiting surgical repair for a severe cyanotic heart
defect.
This parameter is too low. The heart rate should be at least 100 when administering digoxin (Lanoxin)
to an infant.
An infant with a con- genital heart defect frequently requires formula with extra calories per ounce.
Regular Enfamil formula would not provide sufficient calories.
A nurse would be most correct in withholding digoxin (Lanoxin) prescribed to an infant if the heart
rate falls below which parameter?
A) Below 100 beats per minute.
B) Below 120 beats per minute.
C) Below 140 beats per minute.
D) Below 160 beats per minute. - ANSWER: A) Below 100 beats per minute.
Rationale - digoxin (Lanoxin) should be withheld if the heart rate of the infant falls below 90 to 110
beats per minute (bpm). If digoxin (Lanoxin) is given when the infant's heart rate is 100, the resulting
cardiac output may not be adequate.
A hospitalized child is experiencing sickle cell vaso-occlusive crisis. The child is currently receiving an
intra- venous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities
per physician orders. During the midday assessment, the child reports no pain. Which action should a
nurse take?
A) Continue to apply warm compresses per physician order.
B) Hold the next dosage of pain medication.
C) Hold the next round of warm compresses.
D) Contact the physician for a change in orders. - ANSWER: A) Continue to apply warm compresses
per physician order.
Rationale - The child is currently receiving a fluid bolus, which may be providing temporary
improvement of pain symptoms. Ongoing application of warm compresses will continue to promote
circulation in the extremities, thereby preventing pain. Once the fluid bolus is completed, the nurse
should reassess the child's pain and circulation.
, What should be the expected weight of an infant at 12 months of age whose birth weight was 3600
grams?
A) 5600 grams.
B) 7200 grams.
C) 11 kilograms.
D) 15 kilograms. - ANSWER: C) 11 kilograms.
Rationale - An infant is expected to triple its birth weight in the first year of life; therefore, 11
kilograms (11,000 grams) is the best answer of the options given.
An infant in a newborn nursery is identified as having phenylketonuria (PKU). What is the best initial
source of nutrients for an infant with this diagnosis?
A) Maternal breast milk.
B) Pregestimil.
C) Lofenalac.
D) Isomil. - ANSWER: A) Maternal breast milk
Rationale - The child with PKU is missing the enzyme needed to digest the amino acid phenylalanine.
Maternal breast milk has many beneficial properties and it contains low levels of phenylalanine.
Therefore, breast milk should be given until laboratory findings demonstrate the child is not tolerating
the breast milk.
In assessing the reflexes of a 15-month-old child, which finding would indicate that the child is
experiencing normal development?
A) Positive Babinski reflex.
B) Asymmetric tonic neck reflex.
C) Positive patellar reflex.
D) Presence of doll's eye reflex. - ANSWER: C) Positive patellar reflex.
Rationale - A positive patellar reflex is part of a normal assessment. The reflex is obtained when the
practitioner strikes the patellar tendon, causing the leg to kick.
A child with type 1 diabetes is receiving insulin based on carbohydrate intake. The child's insulin-to-
carbohydrate ratio is 15:1. Of the items listed on the child's lunch menu shown below, the child ate 2
slices of bread, a slice of cheese, a glass of milk, a cup of soup, and half of a banana. How many units
of insulin should the nurse administer based on the client's carbohydrate count? Round to the nearest
whole number.
Food Item with Carbohydrate level:
Banana 22g
Glass of low-fat milk 10g Bread slice 15g
Cheese slice Free
Cup of soup 10g
A) 2 units.
B) 3 units.
C) 4 units.
D) 5 units. - ANSWER: C) 4 units
Rationale - 4 units of insulin would be required to metabolize 61 carbohydrates based on an insulin-
to-carbohydrate ratio of 15:1.
A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the
nurse's first priority when caring for this child?
Components of Nursing Care, 3rd Edition by Kathryn Rudd
9781719645706 , All Chapters with Answers and Rationals
A nurse is caring for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH).
Which laboratory test would the nurse be least likely to obtain?
A) Urine specific gravity.
B) Blood glucose.
C) Serum sodium.
D) Urine osmolality. - ANSWER: B) Blood Glucose
Obtaining a blood glucose level is not expected for a child diagnosed with SIADH since the priority
measures involve blood and urine osmolality. Blood glucose is a likely laboratory test in a child with
diabetes insipidus.
A physician prescribes digoxin (Lanoxin) for a toddler with congestive heart failure (CHF). Before
administering the medication, it is most important for the nurse to:
A) First obtain an apical heart rate.
B) Determine the serum potassium.
C) Review the child's admission electrocardiogram (ECG).
D) Mix the medication with a pleasant-tasting food. - ANSWER: A) First obtain an apical heart rate
Rationale - Apical heart rate must be obtained by the nurse prior to the administration of digoxin
(Lanoxin) to a child. Unless otherwise prescribed, the medication is typically withheld for a heart rate
below 90 to 110 bpm in young children
A nurse prepares to administer spironolactone (Aldactone) to an infant with congenital heart disease.
The nurse understands that the main purpose of this medication is to:
A) Preserve the patent ductus arteriosus.
B) Cause vasodilation of the blood vessels.
C) Prevent the secretion of potassium.
D) Block aldosterone, which leads to diuresis. - ANSWER: D) Block aldosterone, which leads to
diuresis.
Rationale - Spironolactone (Aldactone) is a diuretic that blocks aldosterone. Use of this medication is
common among children with congenital heart disease for the prevention and treatment of
congestive heart failure.
Which symptom(s), if present in a child, should a nurse recognize as being characteristic of Kawasaki
disease? Select all that apply.
A) Strawberry tongue.
B) High fever.
C) Irritability.
D) Cough.
E) Desquamation of the extremities.
F) Elevated ESR. - ANSWER: A) Strawberry tongue.
B) High fever.
C) Irritability.
E) Desquamation of the extremities.
F) Elevated ESR.
,Rationale - Strawberry tongue is a symptom of Kawasaki disease (mucocutaneous lymph node
syndrome), occur- ring as the skin of the tongue sloughs off, leaving a bright red tongue with white
spots. A symptom of Kawasaki disease is high fever lasting more than 5 days. Irritability is a symptom
of Kawasaki disease.
The child with Kawasaki disease may experience peeling of the hands (on palms and fingertips) and
feet (on soles and tips of toes) following the initial inflammatory rash on these areas.
An elevated erythrocyte sedimentation rate (ESR) is a symptom of Kawasaki disease. Elevated ESR is
indicative of an inflammatory process, which would include Kawasaki disease.
Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome
who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
A) Call physician for oxygen saturations below 85%.
B) Daily weights.
C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
D) Strict I&O.
E) Enfamil formula ad lib. - ANSWER: A) Call physician for oxygen saturations below 85%.
C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
E) Enfamil formula ad lib.
Rationale - The nurse should question an order that requires the nurse to call the physician for an
oxygen saturation that is appropriate for an infant waiting surgical repair for a severe cyanotic heart
defect.
This parameter is too low. The heart rate should be at least 100 when administering digoxin (Lanoxin)
to an infant.
An infant with a con- genital heart defect frequently requires formula with extra calories per ounce.
Regular Enfamil formula would not provide sufficient calories.
A nurse would be most correct in withholding digoxin (Lanoxin) prescribed to an infant if the heart
rate falls below which parameter?
A) Below 100 beats per minute.
B) Below 120 beats per minute.
C) Below 140 beats per minute.
D) Below 160 beats per minute. - ANSWER: A) Below 100 beats per minute.
Rationale - digoxin (Lanoxin) should be withheld if the heart rate of the infant falls below 90 to 110
beats per minute (bpm). If digoxin (Lanoxin) is given when the infant's heart rate is 100, the resulting
cardiac output may not be adequate.
A hospitalized child is experiencing sickle cell vaso-occlusive crisis. The child is currently receiving an
intra- venous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities
per physician orders. During the midday assessment, the child reports no pain. Which action should a
nurse take?
A) Continue to apply warm compresses per physician order.
B) Hold the next dosage of pain medication.
C) Hold the next round of warm compresses.
D) Contact the physician for a change in orders. - ANSWER: A) Continue to apply warm compresses
per physician order.
Rationale - The child is currently receiving a fluid bolus, which may be providing temporary
improvement of pain symptoms. Ongoing application of warm compresses will continue to promote
circulation in the extremities, thereby preventing pain. Once the fluid bolus is completed, the nurse
should reassess the child's pain and circulation.
, What should be the expected weight of an infant at 12 months of age whose birth weight was 3600
grams?
A) 5600 grams.
B) 7200 grams.
C) 11 kilograms.
D) 15 kilograms. - ANSWER: C) 11 kilograms.
Rationale - An infant is expected to triple its birth weight in the first year of life; therefore, 11
kilograms (11,000 grams) is the best answer of the options given.
An infant in a newborn nursery is identified as having phenylketonuria (PKU). What is the best initial
source of nutrients for an infant with this diagnosis?
A) Maternal breast milk.
B) Pregestimil.
C) Lofenalac.
D) Isomil. - ANSWER: A) Maternal breast milk
Rationale - The child with PKU is missing the enzyme needed to digest the amino acid phenylalanine.
Maternal breast milk has many beneficial properties and it contains low levels of phenylalanine.
Therefore, breast milk should be given until laboratory findings demonstrate the child is not tolerating
the breast milk.
In assessing the reflexes of a 15-month-old child, which finding would indicate that the child is
experiencing normal development?
A) Positive Babinski reflex.
B) Asymmetric tonic neck reflex.
C) Positive patellar reflex.
D) Presence of doll's eye reflex. - ANSWER: C) Positive patellar reflex.
Rationale - A positive patellar reflex is part of a normal assessment. The reflex is obtained when the
practitioner strikes the patellar tendon, causing the leg to kick.
A child with type 1 diabetes is receiving insulin based on carbohydrate intake. The child's insulin-to-
carbohydrate ratio is 15:1. Of the items listed on the child's lunch menu shown below, the child ate 2
slices of bread, a slice of cheese, a glass of milk, a cup of soup, and half of a banana. How many units
of insulin should the nurse administer based on the client's carbohydrate count? Round to the nearest
whole number.
Food Item with Carbohydrate level:
Banana 22g
Glass of low-fat milk 10g Bread slice 15g
Cheese slice Free
Cup of soup 10g
A) 2 units.
B) 3 units.
C) 4 units.
D) 5 units. - ANSWER: C) 4 units
Rationale - 4 units of insulin would be required to metabolize 61 carbohydrates based on an insulin-
to-carbohydrate ratio of 15:1.
A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the
nurse's first priority when caring for this child?
