Plan of care for a client who has gastroenteritis ati

1) A nurse is assisting a child who has multiple closed fractures of the lower extremities due to a motor-vehicle crash. The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred?

a. Osteomyelitis

b. Compartment syndrome

c. Volkmann ischemic contracture

d. Renal calculi

2) A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning. Which of the following information should the nurse include in the teaching?

a. Use aspartame as sugar substitute

b. Avoid foods containing milk products

c. Increase the toddlers protein consumption

d. Limit foods high in iron

3) A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

a. Vary daily routines when providing care for the child

b. Keep the television on in the child’s room for background noise

c. Keep staff visits with the child brief

d. Place the child in a semi private room.

4) A nurse is assisting an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?

a. Increase urine output

b. Hypertension

c. Increase respiratory rate

d. Capillary refill of 2 seconds

5) A nurse is planning care for a child who has cystic fibrosis. Which of the following interventions should the nurse plan to include?

a. Restrict the child’s physical activity to promote rest

b. Administer pancreatic enzymes by mouth 1 hr. prior to each meal

c. Provide the child with low sodium diet

d. Use a vest to perform high-frequency chest compressions

6) A nurse is teaching the parent of a school age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

a. Your child’s feet should be 3 to 6 inches off the ground when seated on the bicycle

b. Your child should walk the bicycle through intersections

c. Your child should keep the bicycle at least 3 feet from the curb while riding in the street

d. Your child should ride the bicycle against the flow of traffic

7) A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?

a. Lateral

b. Prone

c. Semi-fowler

d. Supine

8) A nurse is reviewing the complete blood count results for a child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?

a. WBC count 15.000/mm

b. Hemoglobin 6.8 g/dL

c. Platelet count 98.0000/mm

d. RBC count 5/mm

9) A nurse is caring for a school age child who has pertussis. Which of the following actions should the nurse take?

a. Report the diagnosis to the public health department

b. Place the child in a protected environment for 48hr

c. Administer the pertussis vaccine

d. Restrict oral fluids to 500mL per day

10) A nurse is assessing a week old infant. The nurse should identify which of the following manifestations can indicate neonatal abstinence syndrome?

a. Frequent coughing

b. Constipation

c. Excessive sucking

d. Lethargy

11 )A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month-old infant. Which of the following actions should the nurse plan to take?

a. Use a 12 gauge catheter to the start the IV

b. Start the IV in the infant’s foot

c. Cover the insertion site with an opaque dressing

d. Change the IV site every 3 days

12) A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?

a. Weak pedal pulse distal to the site

b. Blood pressure 102/58mm Hg

c. Bilateral cool extremities

d. Serum glucose 90mg/dL

18) A nurse is providing teaching to the parents of a child who has varicella about management of the disease. Which of the following instructions should the nurse include in the teaching?

a. Avoid giving the child a bath while vesicles are present

b. Keep the child away from others until the skin is clever of scabs

c. Apply calamine lotion to vesicles on the child's skin

d. Dress the child in warm clothing to promote healing of the vesicles

30) A nurse is planning care for a child who is experiencing a sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?

a. Administer meperidine as needed for plan

b. Initiate bed rest

c. Limit fluid intake

d. Apply cold compresses to affected joints

31) A charge nurses teaching a group of nurses about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse?

a. An 8 month old infant cries when his parents leave the room

b. A toddler repeatedly refuses to let a nurse auscultate his lungs

c. A toddler has bruises on his knees

d. A mother is hesitant to comfort her 6 month old infant

32) A nurse is teaching the guardian of a 5 year old child who has encopresis about management of the condition. Which of the following statements by the guardian indicates an understanding of the teaching?

a. I will limit my child's fluid intake

b. I will increase my child's dairy intake

c. I will have my child sit in the toilet for 2o minutes at a time

d. I will have my child try to defecate 15 minutes after each meal

33) A nurse is assisting an infant who has respiratory syncytial virus. For which of the following findings should the nurse intervene?

a. Brisk capillary refill

b. Tachypnea

c. Rhinorrhea

d. Coughing

34) A nurse is performing a health assessment for a 6 month old infant. The nurse should begin the assessment by performing which of the following actions while the infant is quiet and sitting on the guardians lap?

a. Obtaining the infant's health history from the guardian

b. Checking the infant reflexes

c. Listening to the infinite heart and lung sounds

d. Looking in the infants eyes

35) A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first

a. Administer an antidepressant to the client

b. As the client if he is considering harming himself

c. Encourage the client to attend a group therapy session

d. assist the client in completing his ADLs

36) A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?

a. Dark brown blood noted in emesis

b. Axillary temperature 38 C (100 F)

c. Child resorts pain level 5 on FACES scale

d. Frequent swallowing

37) A nurse in the emergency department is caring for a school age child who has developed respiratory stridor, wheezing, and urticarial after receiving an IV medication. Which of the following actions should the nurse take first?

a. Administer oxygen

b. Ad mister methylprednisolone

c. Administer a nebulized bronchodilator

d. Administer epinephrine

38) A nurse is caring for an infant who has a patent ductus arteriosus. The nurse should identify that the defect is at which of the following locations of the heart? ( You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

B

A

C

D

The correct answer is =

39) A nurse is caring for a school aged child who is 1hr postoperative following a tonsillectomy. Which of the following actions should the nurse take first? ( Select all that apply)

a. Maintain the child in a supine position

b. Observe the child for frequent swallowing

c. Discourage the child from coughing

d. Administer an analgesic to the child on a scheduled basis

e. Provide cranberry juice to the child

40) a nurse is teaching the guardian of an infant who has congestive heart failure about methods to preserve energy during bottle feeding. Which of the following statements by the guardian indicates a clear understanding of the teaching?

a. I will feed my baby every 2 hours

b. I will allow my baby to suck for 45 minutes during each feeding

c. I will use a low calorie formula for my baby's feeding

d. I will stroke my baby's cheek during feeding

41) A nurse in a family practice clinic is assessing a preschool age child who recently experienced the death of a sibling. Which of the following reactions in an age appropriate response to death?

a. The child view the siblings death as permanent

b. The child feels responsible for the siblings death

c. The child can give a logical explanation for the siblings death

d. The child is curious about what happened to the siblings body

59) A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates a clear understanding of the teaching?

a. I should mix the medication with 4 ounces of my child's favorite juice

b. I should give my child another dose if he vomits right after taking the medication

c. I should give my child water after giving the medication

d. I should give the medication with foods that are high in fiber

60) A nurse is providing a teaching to the guardian of a 2year old about typical toddler behavior. Which of the following behaviors should the nurse include?

a. Frequency negative responses

b. Less emotionally labile

c. Increased dependency

d. Resistant to routines

61) A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?

a. Tighten the screws on the halo device one quarter turn every 48 hr

b. Encourage flexion and extension of the neck

c. Reposition the client using a turning sheet

d. Asses the pin sites for an infection once every other day

62) A nurse is caring for a 1 year old infant who has GERD. Which of the following actions should the nurse take to promote sleep for the infant?

a. Place the infant in surprise position to sleep

b. Place the infant in a left lateral position’

c. Offer feedings just before bedtime

d. Provide the infant with a bottle of milk at bedtime

63) A nurse is assessing a toddler who has a history of lead poisoning. Which of the following actions should the nurse take?

a. Obtain a stool specimen for lead levels

b. Initiate a low iron diet for lead absorption

c. Perform development testing for delays

d. Inspect the skin for discoloration

64) A nurse is collecting data from a toddler who weighs 25 kg (44ib) and has a full thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?

a. Respiratory rate 25/min

b. Bowl sounds 20/min

c. Increased restlessness

d. Urinary output 35mL//hr

65) A nurse is educating an adolescent following the application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?

a. I will sprinkle baby powder into the cast if my arm itches

b. I should limit the use of fingers of my broken arm

c. I will elevate my broken arm on pillows a tonight

d. I should expect my fingers to be swollen for several days

66) A nurse is teaching a parent about home interventions for a preschooler who is experiencing night terrors. Which of the following instructions should the nurse include in the teaching?

a. Wake your child up from the night terrors

b. Avoid allowing your child to sleep in your bed

c. Allow your child to watch an animated movie right before bedtime

d. Wait until your child indicates that he is tired before putting him to bed

67) A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the client's potassium level is 3.2 mEq/L. Which of the following assessment findings should the nurse expect?

a. Hypertension

b. Hyperreflexia

c. Hyperactive bowel sounds

d. Oliguria

68) A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?

a. Tachypnea

b. Increased appetite

c. Tremors

d. Bradycardia

69) A nurse is planning to administer ondansetron 0.15 mg/kg IV to a child who is receiving chemotherapy and weighs 29.4kg. Available is ondansetron 4 mg/2 solution. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

--------- mL

13. A nurse is caring for an adolescent who has scoliosis and is refusing to wear a back brace which of the following statement should the nurse make?

a. I think you are worrying too much about wearing the brace.

b. Let’s sit down and discuss why you do not want to wear the brace.

c. your primary care provider said you have to wear a brace.

d. At first it is hard to wear a back brace but it gets easier over time.

14. A nurse is providing teaching to a parent of a child who has HIV. which of the following statements by the parent indicates an understanding of the teaching?

a. I will ensure that my child is tested for tuberculosis every year.

b. my child will need to double his medications for the next 6 months.

c. the risk of transmission decreases once my child is on zidovudine for 2 weeks.

d. my child will need to repeat his childhood immunizations once he is in remission.

15.A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide. Which of the following finding is the nurse’s priority ?

a. heart rate 162/min

b. negative doll’s eye reflex.

c. Sunken anterior fontanel

d. potassium 5.1MEq/L

16.A nurse in an emergency department is caring for a child who experienced submersion injury. Which of the following is the priority action for the nurse to take?

a. obtain an ABG sample.

b. Apply warming blankets.

c. Assist with intubation.

d. Administer an IV bolus.

17.A nurse is caring for a school- age child who is experiencing a sickle cell crisis. Which of the following action s should the nurse take ?

a.initiate contact precaution

b. Apply warm compresses to the affected area.

c. Decrease the child’s fluid intake.

administer furosemide IV twice per day.

19. A nurse is planning care for an adolescent following repair of Meckel diverticulum. Which of the following action should the nurse include in the plan of care?

a. Teach the client about ostomy care.

b. Maintain an NG tube for decompression.

c. initiate long- term antibiotic therapy.

d. Administer total parenteral nutrition.

20. A nurse is teaching a parent of a10-month-old infant about home safety. Which of the following instructions should the nurse include in the teaching?( select all that apply).

a. place gate at the top and bottom of the stairs.

b. Ensure the crib mattress is in the lowest position.

c. Remove labels from containers that contain toxic substance.

d. Keep toilet lids in the upright position.

e. select a toy chest that has a heavy, hinged lid.

21. A nurse is communicating with a child who had hearing loss. Which of the following action should the nurse take?

a. Maintain a neutral facial expression when speaking to the child.

b. Change position s frequently to maintain the child’s attention.

c. Exaggerate the pronunciation of words.

d. use light touch when initiating conversation.

22. A nurse is creating plan of care for an adolescent who has muscular dystrophy. Which of the following intervention should the include in the plan ?

a. Avid influenza and pneumococcal vaccines foe 24 months.

b. initiate a referral for chest physiotherapy every 4hr.

c .recommend the adolescent use a wheel chair to prevent stress the lower extremities.

Encourage the adolescent to perform incentive spirometry to maintain lung capacity.

23. A nurse is creating a plan of care for a toddler who is recovering following a routine surgical procedure. Which of the following interventions should the include.

a. Place cooling blanket on the toddler.

b. Administer IV dantrolene sodium to the toddler.

c. encourage the toddler to use an incentive spirometer.

d. Administer aspirin to the toddler as needed for pain.

24. a nurse is caring for a child who has bacterial meningitis. Which of the following finding s should indicate to the nurse that the child can be removed from droplet precaution?

a. antibiotics initiated 24hr ago

b. Absent nuchal rigidity.

c. Temperature below 37.4 C ( 99.3 F).

d. Negative cerebrospirul fluid culture.

25. A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which of the following restraints should the nurse plan to use for this this procedure.

a. Mummy

b. Elbow

c. Mitten

d. Jacket

27. a nurse is planning to perform tracheostomy care for a toddler . which of the following is an appropriated action for nurse to take?

a. use clean technique to change the tracheostomy tube.

b. clean around the stoma with full –strength hydrogen peroxide.

c. Place the child in Trendelenburg position when performing care.

d. Have the child flex his head when securing the ties.

28. A nurse is teaching an adolescent who has type1 diabetes mellitus. Which of the following finding is the nurse priority?

a. Cholesterol 189mg/dl

b. Glycosuria.

HbA1c11.5%.

d. pre-prandial blood glucose.124mg/dL.

42. A nurse is planning to admit a preschooler from the PACU following removal of a Wilms’ tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler ?

a. A child who has a fractured left femur.

b. A child who has cellulites of the right radius.

c. A child who has impetigo.

d. A child who has viral pneumonia.

43.A nurse is planning to administer immunizations to a 2-month –old infant. Which of the following actions should the nurse take to decrease the infant pain.

a. apply a warm pack to the injection site prior to administration.

b. Ask the parent to leave the room during the injections.

c. Administer the injections in the deltoid muscle.

d. Administer the injections while the infant is breastfeeding.

44. A nurse is caring for a 4-year old child who is postoperative following an appendectomy. Which of the following pain rating scales should the nurse use to assess the child’s need for pain medication ?

a. word –graphic

b. Visual analog

c. FACE

d. Numeric

45. A nurse is reviewing the medical record of a 15-month –old child who is schedule to receive the measles. Mumps. And rubella MMR vaccine. Which of the following finding should the nurse identify as a contraindication for receiving this vaccine.

a. Allergy to neomycin

b. Temperature of 37.2. C (99.F) .

C. Family history of seizures.

d. upper respiratory infection 2days ago.

46A nurse is caring for a child who received partial –thickness burn s to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following action should the nurse take? ( select all that apply.).

a. provide a high-calories diet.

b. Administer analgesics IM .

monitor intake and output

d. remove splints during sleep.

e. change dressing using aseptic technique.

47. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunization should the nurse include in the plan?

a. pneumococcal conjugate (PCV13)

b. Respiratory syncytial virus (RSV).

c. Measles, Mumps, and rubella MMR

d. Rotavirus.

48. A nurse is assessing an client who has Hodgkin’s lymphoma .which of the following finding s should the nurse expect?

a. unexplained weight gain

b. Flushed skin

c. decrease body temperature

d. night sweat.

49. A nurse is teaching a group of parents about childhood immunizations. The nurse should identify that infant should receive the first dose of which of the following immunizations.at 12 months of age.

a. human papillomavirus.

b. inactivated polio virus

c. hepatitis B

Varicella.

50. A nurse in a community clinic is reviewing the laboratory result of four client s. the nurse should identify that which of the following sexually transmitted infections is nationally notifiable. ?

a. Bacterial vaginosis trichinosis’s.

b. Gonorrhea

c. Human Papilloma virus.

d. Genital Herpes Simplex- virus.

51.A nurse is caring for a group of client s. which of the following findings should the nurse report to the provider ?

a. An 18 –month –old toddler who has a heart rate of 68/min.

b. A school-age child who has a rectal body temperature of 37.3C ( 99.1F).

c .A 3-month old infant who has a respiratory rate of 30/min.

d. An adolescent who has a BP of 132/82 mm/Hg.

52. A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider.

A. diplopia.

b. Pruritus

c. hyperactivity.

d. Nightmare.

53. a nurse is admitting a child who has acute epiglottitis. Which of the following action should the nurse take?

a. initiate droplet isolation precaution.

b. Assist the child into supine position.

c. check oxygen saturation every 4 hr.

d. obtain a throat culture.

54. A nurse is caring for an infant who has increase intracranial pressure (ICP). Which of th following should the nurse identify as late finding of (ICP) ?

a. Flexion posturing

b. increase sensory response to painful stimuli.

C increase heart rate

d. Tachypnea.

55. A nurse is assessing a 24- month –old toddler. Which of the following finding should the nurse report to the provider ?

a. Has a vocabulary of 30 words.

b. sleep 11 to 12 hr. per day.

c. Eats a large amount of food one day then very little the next

d. hold his breath when having a temper tantrum.

56. A nurse is teaching about growth and development to a parent of 12 year-old child .the nurse should instruct the parent to expect the child to exhibit which of the following characteristics during early adolescent.

a. decelerating growth rate

b. increase self-esteem.

c. emotional separation from parent.

d. mood swing.

57. A nurse is evaluating 4-year –old child who has cystic fibrosis and has been receiving chest physiotherapy treatments the nurse should identify which of the following finding as an indication that the therapy has been effective ?

a. increase urine output

b. increase heart rate

increase expectoration

d. reduce pain.

58. A nurse is providing teaching to the guardians of an infant who require a pavlik harness. Which instructions should the nurse include ?

a apply baby power under the hardness straps daily.

b. place the diaper under the straps of the hardness.

c. adjust the hardness straps daily.

massage lotion into the skin under the hardness twice per daily.