Maintaining adequate hydration - ANS When caring for a child with congenital heart disease and
polycythemia, which nursing action has the highest priority?
-baked chicken
-coleslaw
-soda
-frozen dessert - ANS The nurse is preparing a teaching plan for the mother of a child who has
been diagnosed with celiac disease. Choosing which lunch would be within therapeutic
management of a child with celiac disease?
-"my son often chokes when I am feeding him" - ANS A 7month old infant diagnosed with
spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants
immediate intervention by the nurse?
-place the child on a clear liquid diet - ANS The nurse is caring for a child with intussusception
who is scheduled for a barium enema prior to a surgical procedure. Which action should the
nurse take first?
-allow the child to assume the knee-to-chest position, with the head and chest slightly elevated.
- ANS The nurse should teach the parents of a child with a cyanotic heart defect to perform
which action when a hyper cyanotic spell occurs?
-exhibits a sudden and unexplained weight gain - ANS The nurse is teaching the parents of a 2
year old with congenital heart defect about signs and symptoms of congestive heart failure.
Which information about the child is most important for the parents to report to the healthcare
provider?
-urinary catheterization - ANS Prophylactic antibiotics are prescribed for a child who has mitral
valve damage. The nurse should advise the parents to give the antibiotics prior to which
occurrence?
-Insert an intravenous (IV) line and begin IV fluids. - ANS A 7-month-old infant with a rotavirus
causing severe diarrhea is admitted for treatment. Which action should the nurse take first?
-Place a do not palpate abdomen sign on head of bed. - ANS The nurse admits a child to the
intensive care unit with a possible diagnosis of Wilms tumor. What is the most important safety
precaution for child?
, - "My husband and our daughter are both lactose-intolerant." - ANS The nurse is taking the
family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the
mother is most important in formulating a plan of care for this child?
-Bring the child to the clinic today for an examination related to the cough. - ANS A mother calls
the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the
previous 10 days, continues to have a cough that she reports is worsening. Further questioning
by the nurse reveals that the cough is nonproductive. What is the nurse's best instruction to the
mother?
- "Tell me what you know about birth control." - ANS The nurse is assessing a male adolescent
client's knowledge of contraception. The teen states, "I have all the info I need." What is the best
response by the nurse?
-Joint inflammation - ANS The nurse is examining a male child experiencing an exacerbation of
juvenile rheumatoid arthritis (JRA) and notes that mobility is greatly reduced. What is the most
likely cause of the child's impaired mobility?
-Tell the parent to take the child to the emergency department. - ANS A father of a 5-year-old
calls the nurse to report that his child, who has had an upper respiratory infection, is
complaining of a headache, with a rectal temperature of 103°F/39.4°C. Which action has the
highest priority?
-Send the child home with the parents to see the healthcare provider before returning to school.
- ANS A child comes to the school nurse complaining of itching. Further assessment reveals
that the child has impetigo. What action should the nurse take?
-Obtain a therapeutic drug level. - ANS An infant is receiving digoxin for congestive heart failure.
The apical heart rate is assessed at 80 beats/min. What action should the nurse take first?
-Assess the child's mucous membranes and skin turgor. - ANS The nurse is conducting an initial
admission assessment of a 12-month-old child in celiac crisis. Which action is most important
for the nurse to take first?
-Monitor the infant's heart rate. - ANS When inserting a nasogastric tube into the stomach of a
3-month-old infant, which action is most important for the nurse to take first?
- Use designated isolation precautions. - ANS The nurse assigns an unlicensed assistive
personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis.
What is the most important instruction for the nurse to review with the UAP?
-Place suctioning supplies on the back of the wheelchair when transporting. - ANS The nurse is
helping a family prepare to send their 7-year-old child to school for the first time. The child is
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