Chapter 23: Pediatric Nursing Interventions and Skills My Nursing Test Banks

Chapter 23: Pediatric Nursing Interventions and Skills

MULTIPLE CHOICE

1. A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source?

a.

Herself

b.

Her mother

c.

Court order

d.

Legal guardian

ANS: A

Contraceptive advice is one of the conditions that is considered medically emancipated. The adolescent is able to provide her own informed consent.

DIF: Cognitive Level: Applying REF: p. 884

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation?

a.

Tell him that this procedure will help him get well faster.

b.

Take his blood pressure when a parent is there to comfort him.

c.

Explain to him how the blood flows through the arm and why the blood pressure is important.

d.

Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.

ANS: D

A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple terms and allow the child to see how the equipment works. This will help allay fears of bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure may be needed before the parent is available. Explaining to a preschooler how the blood flows through the artery and why the blood pressure is important is too complex.

DIF: Cognitive Level: Understanding REF: p. 886

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time??

a.

Allow her to wear her underpants.

b.

Discuss with her mother why this is important to the child.

c.

Ask her mother to explain to her why she cannot wear them.

d.

Explain in a kind, matter-of-fact manner that this is hospital policy.

ANS: A

It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.

DIF: Cognitive Level: Applying REF: p. 887

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4. Using knowledge of child development, what approach is best when preparing a toddler for a procedure?

a.

Avoid asking the child to make choices.

b.

Plan for a teaching session to last about 20 minutes.

c.

Demonstrate on a doll how the procedure will be done.

d.

Show the necessary equipment without allowing child to handle it.

ANS: C

Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the childs favorite doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.

DIF: Cognitive Level: Applying REF: p. 887 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

5. The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

a.

Explain that it will not be painful.

b.

Suggest to him that he not worry about losing just a little bit of blood.

c.

Discuss with him how his body is always in the process of making blood.

d.

Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.

ANS: C

School-age children can understand that blood can be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears.

DIF: Cognitive Level: Applying REF: p. 907

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

6. A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?

a.

Holding your child is unsafe.

b.

Holding may help your child relax.

c.

Hospital policy prohibits this interaction.

d.

Holding your child is unnecessary given the childs age.

ANS: B

The mothers preference for assisting, observing, or waiting outside the room should be assessed, as well as the childs preference for parental presence. The childs choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care.

DIF: Cognitive Level: Applying REF: p. 907

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

7. A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?

a.

Give him a large cup with ice so it tastes better.

b.

Restrict him to his room until he drinks the GoLYTELY.

c.

Use little cups and make a game to reward him for each cup he drinks.

d.

Tell him that if he does not finish drinking by a set time, the practitioner will be angry.

ANS: C

One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most likely not be effective.

DIF: Cognitive Level: Applying REF: p. 915

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?

a.

Administering preoperative antibiotic

b.

Verifying that the child and procedure are correct

c.

Ensuring that the toddler has been NPO since midnight

d.

Informing the parents where they can wait during the procedure

ANS: B

The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurses responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction.

DIF: Cognitive Level: Applying REF: p. 915

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

9. A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next action?

a.

Follow the orders and check in 2 hours.

b.

Ask the parents if this is the childs usual heart rate.

c.

Recheck the pulse and blood pressure in 15 minutes.

d.

Notify the surgeon that the child is probably going into shock.

ANS: C

In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the childs condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their childs heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.

DIF: Cognitive Level: Applying REF: p. 892

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

10. A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?

a.

Establish a contract with her, including rewards.

b.

Suggest time-outs when she forgets her medicine.

c.

Discuss with her mother the damaging effects of her rescuing the child.

d.

Ask the child to bring her medicine containers to each appointment so they can be counted.

ANS: A

Many factors can contribute to the childs not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself.

DIF: Cognitive Level: Applying REF: p. 891

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Psychosocial Integrity

11. A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?

a.

Massaging reddened bony prominences

b.

Teaching the parents to turn the child every 4 hours

c.

Ensuring that nutritional intake meets requirements

d.

Minimizing use of extra linens, which can irritate the childs skin

ANS: C

Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the child is the nurses responsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing.

DIF: Cognitive Level: Applying REF: p. 896

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

12. A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?

a.

Request these favorite foods for him.

b.

Identify healthier food choices that he likes.

c.

Explain that he needs fruits and vegetables.

d.

Reward him with ice cream at the end of every meal that he eats.

ANS: A

Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

DIF: Cognitive Level: Applying REF: p. 897

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

13. A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?

a.

Tolerated breakfast well

b.

Finished all of breakfast ordered

c.

One pancake, eggs, and 240 ml OJ

d.

No documentation is needed for this age child.

ANS: C

Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food ordered is known. Nutritional information is essential, especially for children with chronic illnesses.

DIF: Cognitive Level: Applying REF: p. 897

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

14. A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child?

a.

Relief of discomfort

b.

Reassurance that illness is temporary

c.

Prevention of secondary bacterial infection

d.

Avoidance of life-threatening complications

ANS: A

The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of pharmacologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life-threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures.

DIF: Cognitive Level: Analyzing REF: p. 899 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

15. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?

a.

Febrile seizures can result.

b.

Antipyretics may cause malignant hyperthermia.

c.

Antipyretics are of no value in treating hyperthermia.

d.

Liver damage may occur in critically ill children.

ANS: C

Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia.

DIF: Cognitive Level: Applying REF: p. 899

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

16. The nurse gives an injection in a patients room. How should the nurse dispose of the needle?

a.

Remove the needle from the syringe and dispose of it in a proper container.

b.

Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.

c.

Close the safety cover on the needle and return it to the medication preparation area for proper disposal.

d.

Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.

ANS: B

All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patients room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal.

DIF: Cognitive Level: Understanding REF: p. 903

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

17. A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions?

a.

Droplet

b.

Contact

c.

Airborne

d.

Standard

ANS: B

MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism.

DIF: Cognitive Level: Applying REF: p. 902

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

18. An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurses response is best?

a.

Restraints need to be kept on all the time.

b.

That is fine as long as you are with him.

c.

That is fine if we have his parents consent.

d.

The restraints can be off only when the nursing staff is present.

ANS: B

The restraints are necessary to protect the IV site. If the child has appropriate supervision, restraints are not necessary. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal.

DIF: Cognitive Level: Applying REF: p. 903

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

19. A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?

a.

Use an 18-gauge needle if possible.

b.

Show the child the equipment to be used before the procedure.

c.

If not successful after four attempts, have another nurse try.

d.

Restrain the child completely.

ANS: B

To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.

DIF: Cognitive Level: Applying REF: p. 886

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do?

a.

Set up a tray with equipment the same size as for adults.

b.

Apply EMLA to the puncture site 15 minutes before the procedure.

c.

Prepare the child for conscious sedation being used for the procedure.

d.

Reassure the parents that the test is simple, painless, and risk free.

ANS: C

Because of the urgency of the childs condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia will be given for the pain.

DIF: Cognitive Level: Applying REF: p. 907

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

21. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

a.

Apply a urine collection bag to the perineal area.

b.

Tape a small medicine cup inside of the diaper.

c.

Aspirate urine from cotton balls inside the diaper with a syringe without a needle.

d.

Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

ANS: C

To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the childs skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup.

DIF: Cognitive Level: Applying REF: p. 908

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

22. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?

a.

Perform a new venipuncture to obtain the blood sample.

b.

Interrupt the IV fluid and withdraw the blood sample needed.

c.

Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.

d.

Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.

ANS: C

The blood specimen obtained must reflect the appropriate hemodilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The next sample will come from the childs circulating blood. With a central venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline.

DIF: Cognitive Level: Applying REF: p. 921

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

23. The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next?

a.

Keep the childs arm extended while applying a Band-Aid to the site.

b.

Keep the childs arm extended and apply pressure to the site for a few minutes.

c.

Apply a Band-Aid to the site and keep the arm flexed for 10 minutes.

d.

Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.

ANS: B

Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied.

DIF: Cognitive Level: Applying REF: p. 912

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

24. An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which?

a.

Bottle of formula or milk

b.

Any food the child is going to eat

c.

One teaspoon of something sweet-tasting such as jam

d.

Carbonated beverage, which is then poured over crushed ice

ANS: C

Mix the drug with a small amount (about 1 tsp) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat this food in the future.

DIF: Cognitive Level: Applying REF: p. 915

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

25. The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine?

a.

A measuring spoon should be used, and the medication must be given every 6 hours.

b.

The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered.

c.

A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake.

d.

A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time, and before bed.

ANS: C

A hollow-handled medication spoon allows the mother to measure the correct amount of medication. The order is written for four times a day; every 6 hours dosing is not necessary. There is no indication that the mother is not able to adhere to the medication regimen. She is asking for clarification so she can properly care for her child. Long-acting intramuscular antibiotics are not indicated. Household teaspoons vary greatly and should not be used.

DIF: Cognitive Level: Applying REF: p. 915

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

26. Guidelines for intramuscular administration of medication in school-age children include what standard?

a.

Inject medication as rapidly as possible.

b.

Insert needle quickly, using a dartlike motion.

c.

Have the child stand if at all possible and if the child is cooperative.

d.

Penetrate the skin immediately after cleansing the site while the skin is moist.

ANS: B

The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the skin is penetrated. Place the child in a lying or sitting position.

DIF: Cognitive Level: Applying REF: p. 920

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

27. What is an advantage of the ventrogluteal muscle as an injection site in young children?

a.

Easily accessible from many directions

b.

Free of significant nerves and vascular structures

c.

Can be used until child reaches a weight of 9 kg (20 lb)

d.

Increased subcutaneous fat, which provides sustained drug absorption

ANS: B

Being free of significant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site. The ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for the child to be walking. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous.

DIF: Cognitive Level: Analyzing REF: p. 919

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

28. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?

a.

At the lacrimal duct

b.

On the sclera while the child looks to the outside

c.

In the conjunctival sac when the lower eyelid is pulled down

d.

Carefully under the eyelid while it is gently pulled upward

ANS: C

The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug.

DIF: Cognitive Level: Applying REF: p. 931

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

29. What is the best method to verify the placement of a nasogastric tube before each use?

a.

Radiologic confirmation

b.

Auscultation of injected air

c.

Aspiration of stomach contents

d.

Verification of tape placement on tube

ANS: C

Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach.

DIF: Cognitive Level: Applying REF: p. 935

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

30. Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive?

a.

Verify placement before each feeding.

b.

Use a syringe with a plunger to give the infant bolus feedings.

c.

Position the infant on the right side during and after the feeding.

d.

Beefy red tissue around the G-tube site must be reported to the practitioner.

ANS: C

Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is expected.

DIF: Cognitive Level: Applying REF: p. 935

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

31. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

a.

Teaching how to irrigate the colostomy

b.

Protecting the skin around the colostomy

c.

Discussing the implications of a colostomy during puberty

d.

Using simple, straightforward language to prepare the child

ANS: B

Protection of the peristomal skin is a major priority. Well-fitting appliances and skin protectants are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not the infant, need to be prepared for the surgery.

DIF: Cognitive Level: Applying REF: p. 940

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

32. A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old and single and lives with her parents. Who signs the informed consent for the 1-month-old infant?

a.

The infants mother

b.

The maternal grandparents of the infant

c.

The paternal grandparents of the infant

d.

Both the infants mother and the maternal grandparents

ANS: A

An emancipated minor is one who is legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service.

DIF: Cognitive Level: Analyzing REF: p. 884 TOP: Nursing Process: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

33. A preschool child needs a dressing change. To prepare the child, what strategy should the nurse implement?

a.

Explain the procedure using medical terminology.

b.

Plan a 30-minute teaching session.

c.

Give choices when possible but avoid delay.

d.

Allow time after the procedure for questions and discussion.

ANS: C

Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. The other options would not be appropriate for a preschool child.

DIF: Cognitive Level: Applying REF: p. 886

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

34. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?

a.

Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.

b.

Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.

c.

Discourage parent presence during procedures on infants and toddlers.

d.

Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.

ANS: D

To assist the school-age child in meeting Ericksons developmental stage of industry, using simple diagrams of anatomy and physiology to explain a procedure is the accurate guideline. Toddlers should be told about a procedure right before the procedure. School-age children should know about the procedure in advance, not right before, and parents should be present for procedures for infants and toddlers.

DIF: Cognitive Level: Applying REF: p. 887

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

35. A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying loudly. The nurse should take which action?

a.

Have the lab technician stop the procedure until the child stops crying.

b.

Do nothing. Its Okay for a child to cry during a painful procedure.

c.

Tell the child to stop crying; its only a small prick.

d.

Tell the child to stop crying because the procedure is almost over.

ANS: B

The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. It is natural for children to strike out in frustration or to try to avoid stress-provoking situations. The child needs to know that it is all right to cry.

DIF: Cognitive Level: Applying REF: p. 889

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

36. At which age should a nurse keep teaching time short (5 minutes)?

a.

Infant

b.

Toddler

c.

Preschool

d.

School age

ANS: B

Toddlers have limited time concept, and teaching time should be kept short (510 minutes).

DIF: Cognitive Level: Applying REF: p. 883

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

37. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

a.

Retake the temperature in 15 minutes after giving the Tylenol.

b.

Place a warm blanket on the child so chilling does not occur.

c.

Check to be sure the Tylenol dose does not exceed 15 mg/kg.

d.

Use cold compresses instead of Tylenol to control the fever.

ANS: C

Nurses must have an understanding of the safe dosages of medications they administer to children, as well as the expected actions, possible side effects, and signs of toxicity. The recommended doses of acetaminophen should never be exceeded.

DIF: Cognitive Level: Applying REF: p. 899

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

38. The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What should the length of the needle and amount to be given be?

a.

5/8 to 1 inch; 0.5 to 1.0 ml

b.

1 inch to 1 1/2 inch; 1.0 to 2.0 ml

c.

1 inch to 1 1/2 inch; 0.5 to 1.0 ml

d.

5/8 to 1 inch; 0.75 to 2 ml

ANS: A

The length of a needle for an infant should be 5/8 to 1 inch, and the amount of solution should not exceed 1 ml.

DIF: Cognitive Level: Applying REF: p. 917

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

39. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, Do it later, okay? What action should the nurse take?

a.

Postpone starting the IV until the next shift.

b.

Start the IV line and then allow for expression of feelings.

c.

Change the route of the antibiotics to PO.

d.

Postpone starting the IV line until the child is ready.

ANS: B

A school-age child may try to delay the procedure, but it is best to complete the procedure and allow time for the child to express his or her feelings. The nurse should not postpone administering the antibiotic, change it to PO, or wait to start the IV line until the child is ready.

DIF: Cognitive Level: Applying REF: p. 889

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

40. The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first thing the nurse should do?

a.

Check placement of the tube.

b.

Check the pH of the gastric aspirate.

c.

Flush the tube with a small amount of water.

d.

Give the medication and then flush with a small amount of water.

ANS: B

The most accurate way to check the position of the nasogastric tube is by checking the pH. Auscultation as a verification tool is reliable only 60% to 80% of the time and should not be used without additional methods. The tube should not be flushed or the medication administered until placement of the tube is checked.

DIF: Cognitive Level: Applying REF: p. 936

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

41. To facilitate the administration of an oral medication to a preschool-age child, what action should the nurse take?

a.

Dilute the medication in a large amount of favorite liquid and allow the child to hold the cup.

b.

Set limits about the need to take medication and offer praise immediately after the task is accomplished.

c.

Mix the medication in a moderate amount of the childs favorite food.

d.

Explain the purpose of the medication and allow the child time to express resistance before giving the medication.

ANS: B

Nurses who approach children with confidence and who convey the impression that they expect to be successful are less likely to encounter difficulty. It is best to approach a child as though cooperation is expected. The medication should not be placed in a favorite liquid or food. Allowing the child time to express resistance will delay administration of the medication.

DIF: Cognitive Level: Applying REF: p. 887

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

42. A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention should be implemented for the child?

a.

Hold the child while rocking in a chair after each injection.

b.

Prepare the child several hours before the injection is given.

c.

Allow the child to watch a younger child receive an injection.

d.

Encourage the child to draw a picture of the pain experienced when an injection is given.

ANS: A

After the procedure, the child continues to need reassurance that he or she performed well and is accepted and loved. The other options are not appropriate for a toddler.

DIF: Cognitive Level: Applying REF: p. 889

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

43. When checking the intravenous (IV) site on a child, the nurse should take which action?

a.

Look at the site.

b.

Ask the child if the site hurts.

c.

Look at the site while palpating the area.

d.

Take all the tape off, assess the site, and redress.

ANS: C

To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site.

DIF: Cognitive Level: Applying REF: p. 918

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What interventions should be included in the childs care plan? (Select all that apply.)

a.

Place a call light and desired items within reach.

b.

Keep the bed in the highest position with the two side rails up.

c.

Turn off the lights and television at night.

d.

Keep personal belongings and clutter contained in one area of the floor.

e.

Have the child wear an appropriate-size gown and nonskid footwear.

ANS: A, E

Prevention of falls requires alterations in the environment, including keeping call light and desired items within reach and having the child wear appropriate-size gowns and nonskid footwear. The bed should be in the lowest position possible with all the side rails up; at least a dim light should be left on at night; and personal belongings and clutter should not be on the floorthey should be in a cabinet.

DIF: Cognitive Level: Applying REF: p. 901 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

2. What methods should the nurse use to measure compliance to a treatment plan? (Select all that apply.)

a.

Pill counts

b.

Chemical assays

c.

Direct observation

d.

Third-party reporting

e.

Monitoring therapeutic response

ANS: A, B, C, E

Assessment of compliance must include direct measurement techniques. Pill counts, chemical assays, direct observation, and monitoring therapeutic response are direct measurement techniques. Third-party reporting would not always be available and would not be a method to measure compliance.

DIF: Cognitive Level: Applying REF: p. 894 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

3. What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? (Select all that apply.)

a.

Nutrition consults

b.

Using skin moisturizers

c.

Turning the child every 2 hours

d.

Using plastic disposable underpads

e.

Using draw sheets to minimize shear

ANS: A, B, C, E

Interventions found to prevent pressure ulcers in critically ill children include nutrition consults, using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear. Dryweave underpads, not underpads with plastic, should be used to reduce moisture.

DIF: Cognitive Level: Applying REF: p. 896

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

4. The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather for the procedure? (Select all that apply.)

a.

Sterile water

b.

A sterile swab

c.

Syringe with tubing

d.

Sterile normal saline

e.

Tracheal suction catheter

ANS: C, D

Nasal washings may be obtained to identify viral pathogens and guide therapy in some respiratory conditions. The child is placed supine, and 1 to 3 ml of sterile normal saline is instilled with a sterile syringe (without a needle) into one nostril. The contents are aspirated with a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then aspirated to recover the nasal specimen. A tracheal suction catheter would not trap the mucus. Normal saline is used, not sterile water. A sterile swab is used for a throat culture, not for nasal washings.

DIF: Cognitive Level: Applying REF: p. 914

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

5. The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)

a.

The child has a stiff neck.

b.

The fever is over 40.6 C (105 F).

c.

The child is younger than 2 months.

d.

The fever has lasted for more than 3 days.

e.

The fever went away for more than 24 hours and then returned.

ANS: A, B, C

Parents should call the office immediately if a child has a fever over 40.6 C (105 F), the child is younger than 2 months, or the child has a stiff neck. Parents are to call within 24 hours if the fever went away for more than 24 hours and then returned or the fever has lasted for more than 3 days.

DIF: Cognitive Level: Applying REF: p. 900

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

6. What strategies should the nurse implement to assist in feeding a sick child? (Select all that apply.)

a.

Serve large portions.

b.

Make mealtimes pleasant.

c.

Avoid foods that are highly seasoned.

d.

Provide finger foods for young children.

e.

Ensure a variety of foods, textures, and colors.

ANS: B, C, D, E

To assist in feeding a sick child mealtimes should be pleasant; highly seasoned foods should be avoided; finger foods should be provided for young children; and a variety of foods, textures, and colors should be ensured. Small portions, not large, should be served.

DIF: Cognitive Level: Applying REF: p. 898

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

7. What disease processes require contact isolation? (Select all that apply.)

a.

Rotavirus

b.

Hepatitis A

c.

Streptococcal pharyngitis

d.

Mycoplasmal pneumonia

e.

Respiratory syncytial virus

ANS: A, B, E

In addition to Standard Precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patients environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory syncytial virus. Streptococcal pharyngitis and mycoplasmal pneumonia require droplet precautions.

DIF: Cognitive Level: Analyzing REF: p. 902

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

8. What disease processes require airborne precautions? (Select all that apply.)

a.

Measles

b.

Varicella

c.

Pertussis

d.

Meningitis

e.

Tuberculosis

ANS: A, B, E

In addition to Standard Precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and tuberculosis. Pertussis and meningitis require droplet precautions.

DIF: Cognitive Level: Analyzing REF: p. 902

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

9. What are the advantages of an implanted port (Port-a-Cath)? (Select all that apply.)

a.

Reduced risk of infection

b.

Reduced cost for the family

c.

Placed completely under the skin

d.

Easy to use for self-administered infusions

e.

Removal does not require a surgical procedure

ANS: A, B, C

The advantages of an implanted port include reduced risk of infection, reduced cost for the family, and placed completely under the skin. Because it is implanted and must be accessed, it is not easy to use for self-administered infusions, and removal does require a surgical procedure.

DIF: Cognitive Level: Analyzing REF: p. 921 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

10. What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)

a.

Have a tea party.

b.

Use a crazy straw.

c.

Cut gelatin into fun shapes.

d.

Place liquid in large Styrofoam cups.

e.

Make ice pops using the childs favorite juice.

ANS: A, B, C, E

Play activities to encourage fluid intake for a child include tea parties, crazy straws, cutting gelatin into fun shapes, and making ice pops using the childs favorite juice. Small cups, not large Styrofoam cups, should be used.

DIF: Cognitive Level: Applying REF: p. 891

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

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