RN PEDIATRIC NURSING ONLINE PRACTICE 20
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24 A n
1. A nurse in an emergency department is caring for a school-
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age child who is experiencing an anaphylactic reaction. Which of the following i
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s the priority action by the nurse?: Administer epinephrine IM
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Rationale: When using the urgent vs. non-
n n n n n n
urgent approach to client care, the nurse should determine that the priority action is ad
n n n n n n n n n n n n n n
nistering epinephrine IM to the child. During an anaphylactic reaction, histamine releas
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causes bronchoconstriction and vasodilation. This is an emergency because ultimate
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it causes decreased blood return to the heart.
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2. A nurse in a pediatric emergency department is planning care for an ado-
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lescent. Based on the information in the adolescent's medical record, which o
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f the following actions should the nurse plan to take?
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1n/n51
,Select all that apply.: Apply supplemental oxygen
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Rationale: According to the medical record and chest x-
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ray report, the adolescent could potentially have a pneumothorax. Also according to t
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n medical record and chest x- n n n n
ray report, the adolescent's oxygen saturation level is decreasing, which indicates h
n n n n n n n n n n n
oxia. Therefore, the nurse should plan to administer supplemental oxygen.
n n n n n n n n n
Prepare for chest tube insertionn n n n
Rationale: According to the medical record and chest x-
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ray report, the adolescent could potentially have a pneumothorax. A pneumothorax i
n n n n n n n n n n n
he presence of air
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in the pleural cavity, which results in decreased lung expansion. The adolescent could
n n n n n n n n n n n n
xperience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt
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ervention by the provider, such as the placement of a chest tube into the thoracic cavi
n n n n n n n n n n n n n n n
o remove air and fluid from the pleural space, if present, allowing the lung to re-expan
n n n n n n n n n n n n n n n
2n/n51
,3. A nurse in an emergency department is caring for a school-
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age child who has epiglottitis.Which of the following actions should the nurse t
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ake?: Monitor the child's oxygen saturation
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Rationale: The nurse should monitor the child's oxygen saturation level because the ch
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ild is experiencing acute respiratory distress and it is necessary to determine if the ch
n n n n n n n n n n n n n n
ld is responding to treatment.
n n n n
4. A nurse is providing teaching about play activities for social development to
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the guardians of a preschooler.Which of the following play activities should the
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nurse recommend for the child?: Playing dress-up
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3n/n51
, Rationale: The nurse should instruct the guardians that at the preschool age,
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play should focus on social, mental, and physical development. Therefore, playing dr
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ess-up is a recommended play activity for this child.
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5. A nurse is receiving change-of-
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shift report for four children. Which of the following children should the nurse s
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ee first?: A school-
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age child who has sickle cell anemia and reports decreased vision in the left eye
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Rationale: When using the urgent vs. non- n n n n n n
urgent approach to client care, the nurse should determine the priority finding is a rep
n n n n n n n n n n n n n n
ort of decreased vision in the left eye. This finding indicates that the child is experienc
n n n n n n n n n n n n n n n
ng a vaso- n n
occlusive crisis and should be reported to the provider immediately. Therefore, the nur
n n n n n n n n n n n n
se should see this child first.
n n n n n
6. A nurse is providing teaching to the parents of a preschooler who has heart fa
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ilure and a new prescription for digoxin twice daily. Which of the following inst
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4n/n51
n n n n n
24 A n
1. A nurse in an emergency department is caring for a school-
n n n n n n n n n n
age child who is experiencing an anaphylactic reaction. Which of the following i
n n n n n n n n n n n n
s the priority action by the nurse?: Administer epinephrine IM
n n n n n n n n n
Rationale: When using the urgent vs. non-
n n n n n n
urgent approach to client care, the nurse should determine that the priority action is ad
n n n n n n n n n n n n n n
nistering epinephrine IM to the child. During an anaphylactic reaction, histamine releas
n n n n n n n n n n n
causes bronchoconstriction and vasodilation. This is an emergency because ultimate
n n n n n n n n n
it causes decreased blood return to the heart.
n n n n n n n
2. A nurse in a pediatric emergency department is planning care for an ado-
n n n n n n n n n n n n
lescent. Based on the information in the adolescent's medical record, which o
n n n n n n n n n n n n
f the following actions should the nurse plan to take?
n n n n n n n n n
1n/n51
,Select all that apply.: Apply supplemental oxygen
n n n n n n
Rationale: According to the medical record and chest x-
n n n n n n n n
ray report, the adolescent could potentially have a pneumothorax. Also according to t
n n n n n n n n n n n n
n medical record and chest x- n n n n
ray report, the adolescent's oxygen saturation level is decreasing, which indicates h
n n n n n n n n n n n
oxia. Therefore, the nurse should plan to administer supplemental oxygen.
n n n n n n n n n
Prepare for chest tube insertionn n n n
Rationale: According to the medical record and chest x-
n n n n n n n n
ray report, the adolescent could potentially have a pneumothorax. A pneumothorax i
n n n n n n n n n n n
he presence of air
n n n
in the pleural cavity, which results in decreased lung expansion. The adolescent could
n n n n n n n n n n n n
xperience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt
n n n n n n n n n n
ervention by the provider, such as the placement of a chest tube into the thoracic cavi
n n n n n n n n n n n n n n n
o remove air and fluid from the pleural space, if present, allowing the lung to re-expan
n n n n n n n n n n n n n n n
2n/n51
,3. A nurse in an emergency department is caring for a school-
n n n n n n n n n n
age child who has epiglottitis.Which of the following actions should the nurse t
n n n n n n n n n n n n n
ake?: Monitor the child's oxygen saturation
n n n n n
Rationale: The nurse should monitor the child's oxygen saturation level because the ch
n n n n n n n n n n n n
ild is experiencing acute respiratory distress and it is necessary to determine if the ch
n n n n n n n n n n n n n n
ld is responding to treatment.
n n n n
4. A nurse is providing teaching about play activities for social development to
n n n n n n n n n n n
the guardians of a preschooler.Which of the following play activities should the
n n n n n n n n n n n n n
nurse recommend for the child?: Playing dress-up
n n n n n n
3n/n51
, Rationale: The nurse should instruct the guardians that at the preschool age,
n n n n n n n n n n n
play should focus on social, mental, and physical development. Therefore, playing dr
n n n n n n n n n n n
ess-up is a recommended play activity for this child.
n n n n n n n n
5. A nurse is receiving change-of-
n n n n
shift report for four children. Which of the following children should the nurse s
n n n n n n n n n n n n n
ee first?: A school-
n n n
age child who has sickle cell anemia and reports decreased vision in the left eye
n n n n n n n n n n n n n n
Rationale: When using the urgent vs. non- n n n n n n
urgent approach to client care, the nurse should determine the priority finding is a rep
n n n n n n n n n n n n n n
ort of decreased vision in the left eye. This finding indicates that the child is experienc
n n n n n n n n n n n n n n n
ng a vaso- n n
occlusive crisis and should be reported to the provider immediately. Therefore, the nur
n n n n n n n n n n n n
se should see this child first.
n n n n n
6. A nurse is providing teaching to the parents of a preschooler who has heart fa
n n n n n n n n n n n n n n
ilure and a new prescription for digoxin twice daily. Which of the following inst
n n n n n n n n n n n n n
4n/n51
