The nurse is preparing to administer an immunization to a four-year-old child.
Which of the following actions should the nurse plan to take?
A- Place the child in a prone position for the immunization
B- request that the child's caregiver leave the room during the immunization
C- administer the immunization using a 24-gauge needle
D- inject the immunization slowly after aspirating for 3 seconds
C- administer the immunization using a 24-gauge needle; The nurse should administer an
immunization for a 4-year-old child using a 24-
gauge needle to minimize the amount of pain experienced by the toddler.
A nurse is reviewing the laboratory report of an infant who is receiving
treatment for severe dehydration. The nurse should identify which of the
following laboratory values indicates effectiveness of the current treatment?
A- Potassium 2.9 mEq/L
B- sodium 140
C- urine specific gravity 1.035
D- BUN 25 mg
,B- sodium 140; The nurse should identify that a sodium level of 140 mEq/L is within the
expected reference range and indicates the current treatment regimen the infant
is receiving for dehydration is effective.
The nurse is providing teaching about Social Development to the parents of a
preschooler. Which of the following play activities should the nurse
recommend for the child?
A- Play pat-a-cake
B- using a push pull toy
C- creating a scrapbook
D- playing dress-up
D- playing dress-up; The nurse should instruct the parents that at the preschool age, play should
focus
on social, mental, and physical development. Therefore, playing dress-up is a
recommended play activity for this child.
A nurse is teaching the parents of a newborn about ways to prevent sudden
infant death syndrome SIDS. Which of the following instructions should the
nurse include?
A- Place the infant in a prone position to sleep.
B- Allow the infant to sleep on a large pillow.
C- User soft mattress in the infant's crib.
,D- Give the infant a pacifier at bedtime.
D- Give the infant a pacifier at bedtime; The nurse should inform the parent that protective
factors against SIDS include
breastfeeding and the use of a pacifier when the infant is sleeping.
A- The nurse should instruct the parent to place the infant in a supine
A nurse is assessing an infant who has pneumonia. Which of the following
findings is the priority for the nurse to report to the provider?
A- Nasal flaring
B- WBC 11,300
C- diarrhea
D- abdominal distension
A- Nasal flaring; When using the airway, breathing, circulation approach to client care, the nurse
should place the priority on nasal flaring. Nasal flaring indicates that the
infant is experiencing acute respiratory distress.
A school nurse is assessing a school-age child blood pressure while he is seated
in a chair. The child starts to experience a tonic-clonic seizure. Which of the
following actions should the nurse take first?
A- Clear the immediate area around the child of hazardous objects
B- loosen the child restrictive clothing
, C- assist the child to a side-lying position on the floor
D- apply an oxygen mask to the child
C- assist the child to a side-lying position on the floor; The greatest risk to this child is aspiration,
occlusion of the airway, and bodily
injury from falling out of the chair. The nurse should ease the child down to
floor in a side-lying position immediately. This position enables the child's
secretions to drain from the mouth, preventing aspiration, and maintaining a
patent airway.
A nurse is receiving change-of-shift Report on for children. Which of the
following children should the nurse assesses first?
A- A toddler who has a concussion and an episode of forceful vomiting
B- an adolescent who has infective endocarditis and reports having a headache
C- an adolescent who was placed into Halo traction 1 hour ago and rates his pain
at a 6 on a 0-10 scale
D- school-age child who has acute glomerulonephritis and brown colored urine
A- A toddler who has a concussion and an episode of forceful vomiting; When using the urgent vs.
no urgent approach to client care, the nurse should assess
this child first. An episode of forceful vomiting is an indication of increased
intracranial pressure in a toddler who has a concussion.
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