a 2 year old is admitted to the hospital with possible encephalitis, and a lumbar puncture is
scheduled. Which information should the nurse provide this child concerning the procedure? -
ANS - Describe he side-lying, knees to chest position that must be assumed during the
procedure
A 16 year old female student with a history of asthma controlled with both an oral antihistamine
and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student
complains that she cannot sleep at night, feels shaky and her heart feels like it is "beating a mile
per minute" Which information is most important for the nurse to obtain? - ANS - How often the
MDI is used daily
A 16 year old male who has been treated in the past for a seizure disorder is admitted to the
hospital. Immediately after admission he begins to have a Grand Mal seizure. Which action
should the nurse take? - ANS - observe him carefully
A 2 year old boy begins to cry when the mother starts to leave. What is the nurse's best
response to the situation? - ANS - let me read this book to you
A 2 year old child with HF is admitted for replacement of a graft for coarcion of the aorta. Prior to
administering the next dose of digoxin (Lanoxin) the nurse obtains and apical heart rate at 128
bpm. What action should the nurse implement? - ANS - Administer the scheduled dose
A 3 year old boy in a daycare facility scratches his head frequently and the nurse confirms the
presence of head lice. The nurse washes the child's hair with permethrin (Nix) shampoo and call
his parents. What instructions should the nurse provide to the parents about treatment of head
lice? - ANS - Wash the child's bed linens and clothing in hot soapy water
A 3 year old with HIV infection is staying with a foster family who is caring for 3 other foster
children in their home. When one of the children acquires pertussis, the foster mother calls the
clinic and asks then nurse what she should do. Which action should the nurse take first? - ANS -
Review the immunizaiton documentation of the child who has HIV
A 6 year old with asthma is demonstrating a prolonged expiratory phase and wheezing and has
a 35% of personal best peak expiratory flow rate (PEFR) based on these findings, what action
should the nurse take first? - ANS - Administer a prescribed bronchodilator
A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When
obtaining the nursing history which finding should the nurse expect to obtain? - ANS - A recent
strep throat infection
, A 7 year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached
to low intermittent suction is applied. Which finding is most important for the nurse to report to
the healthcare provider? - ANS - Serum potassium of 3.0 mg/dL
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse
determines that the increased respiratory rate is a compensatory mechanism for which acid
base alteration? - ANS - Metabolic Acidoses
A child is brought to the clinic complaining of fever and joint pain, and is DX with rheumatic
fever. When planning care for this child what is the goal of nursing care? - ANS - Prevent
cardiac damage
A child who weighs 25 kg is receiving IV ampicillin 300mg/kg/24 hours in equally divided doses
every 4 hours. How many mg should the nurse administer to the child for each dose? - ANS -
1875mg
A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian
IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse
determines that there are no signs of infection at the site. Which intervention is the most
important for the nurse to implement? - ANS - Obtain specimen for blood cultures
A child with leukemia is admited to chemotherapy and the nursing diagnosis "alered nutrition,
less than boy requirements related to anorexia, nausea, and vomiting" is identified. Which
intervention the nurse included in this childs plan of care? - ANS - Allow the child to eat any food
desired and tolerated
A month old girl is brought to the clinic by her mother because she has had a cold for 2 to 3
days and woke up this morning with a hacking cough and difficulty breathing. Which additional
assessment finding should alert the nurse that the child is in acute respiratory distress? - ANS -
Flaring of the nares
An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. Which action should
the nurse implement first? - ANS - Place the infant in a knee-chest position
During a well baby visit the parents explain that the soft bulge appears in the groin of their 4
month old son when he cries or strains with stool. The infant is scheduled for surgical repair of
the inguinal hernia in 2 weeks. The parent should be instructed to take which measure if the
hernia becomes incarceraed prior to surgery? - ANS - Gently manipulate the hernia for reducion
During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks
for the block. Which normal growth and development milestone is the baby developing? - ANS -
Object Permanence
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