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Duplicate of 2030 Final Review
Duplicate of 2030 Final Review
200 terms
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A final review for 2030.
Flashcards
200 cards
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Practice quiz
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Questions
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Answers
1
A child c/o burning sensation to knee and reluctance to move body part. What should be done?
Begin physical therapy with active ROM
Administer aspirin containing componenet
Initiate skin traction
Institute RICE
2
What is the nurse's first action when a pt has a probable dx of abruptio placentae?
Insert a large gauge IV
Obtain a brief history from the pt
Prepare the pt for a vaginal examination
Prepare the pt fir an ultrasound scan
3
What should the nurse assess first in a kid brought to the ER that is lethargic and dehydrated?
Draw blood for lab tests
Insert and IV and infuse fluids
Obtain vital signs and weight
Apply a urine collection bag
4
What is an appropriate intervention for a fussy 6mo admitted for diarrhea?
Placing a mobile above the crib
Offering a pacifier
Turning TV on to cartoons
Sitting at crib side talking to infant
5
What pt would be a candidate for induction of labor?
Active herpes
Fetus with late deceld
Pregnancy induced hypertension
Face presentation
6
What is the most effective follow up with a child dx with failure to thrive?
Twice weekly clinic appointments
Enrollment in community parenting class
Daily phone calls from hospital nurse
Weekly visits by community health nurse
7
When preparing to administer oral meds to a child, what should the nurse ask the child?
If they want it crushed in applesauce
What time they want to take it
What they would like to drink after
If they will take it now
8
What dairy products can be included in a child's diet that is dx with lactose intolerance?
Cheese
Creamed soups
Pudding
Ice cream
9
A child taking Bactrim for a UTI reports a rash. What should the nurse tell the parents to do?
Use sunblock while on the medication
Increase the child's fluid intake
Apply lotion t affected area
D/C the medication and come for immediate evaluation
10
What is true in a child dx with Salmonella?
Organism is alive forever, but not a danger to others
Some children become carriers and stay infectious
After acute stage, the organism is not present in the stool
If organism stays in stool, an antitoxin can destroy it
11
What is an important finding in a child that has ingested kerosene?
Pneomonitis
Uremia
Hepatitis
Carditis
12
Modifiable health risks include
Smoking
Gender
Family
Age
13
What alerts the nurse to early hemorrhage after a tonsillectomy in a 5 year old?
Vomiting 25ml of dark brown emesis
Blood pressure of 95/56
Drooling of bright red secretions
Pulse rate of 95bpm
14
What should the nurse assess first in a child placed in skeletal traction for a femur fracture?
The Ace bandage
The dressings for tightness
The pull of traction on the pin
The pin sites for signs of infection
15
What should be suggested to a 12yo with asthma to improve oxygenation?
Gymnastics
Swimming
Track
Soccer
16
A nurse notes a separation of abd muscles in a section pt. What is the nurse's next action?
Teach head and shoulder lifting exercises
No further action is needed
Notify dr of separation
Refer client to surgeon for repair 6wks postpartum
17
The nurse should notify the physician immediately with which of the assessment findings?
Three pea sized clots passed 4 hrs after delivery
Firm uterus with steady trickle of blood 2hrs after delivery
Musty odor to lochia 48 hr postpartum
Scant amounts of rubra lochia after c section
18
What is important to teach the new mother that has no immunity against rubella?
D/C breast feeding until you have been vaccinated
Have infant screened for rubella at 2mo check up
Avoid contact with pregnant women
Avoid conception for 2-3 months
19
What should the nurse particularly assess when questioning parents about abusing their child?
Self blame for injury to the child
Attentiveness to child's needs
Ability to relate to child's developmental achievements
Difficulty with controlling aggression
20
What should the nurse tell the breast feeding mother of a baby dx with cow milk sensitivity?
Limit breast feeding to once a day
Continue to breast feed but eliminate all milk products
Change to soy based formula
Stop breast feeding, start predigested formula
21
What is not included in accurately monitoring I&O in a dehydrated child?
Restricting fluids prior to weighing the child
Obtaining a urine specific gravity measure
Obtaining an accurate daily weight
Weighing and recording all wet diapers
22
What is a complication of ingestion of drain cleaner that the Dr needs to be alerted of?
Tracheal varices
Tracheal stenosis
Esophageal diverticula
Esophageal strictures
23
What would indicate that pitocin needs to be stopped?
Contractions lasting 120 seconds
Early fetal heart rate decels on the monitor
Squeezing eyes shut during each contraction
Maternal BP increase from 124/82 to 130/86
24
What behavior indicated effectiveness in tx plan for child with autism?
Plays with one toy for 30 min
Hold parent's hand while walking
Spins around and claps hands while walking
Repeats words spoken by parents
25
What should be included in teaching about hip abduction stabilization bar in hip dysplasia?
It can be adjusted to a position of comfort
It adds strength to the cast
It is necessary to turn the child
It is used to lift the child
26
The nurse instructs the diabetic pt that insulin needs will change during first trimester by?
They will increase
They will be unpredictable
They will decrease
They will remain constant
27
Amniocentesis at 16wks gestation, further teaching needs done after which statement?
Fluid leakage from vagina
Fever
Bleeding from vagina
Absence of fetal movement
28
When should the parent obtain a tape test in the child with suspected pinworms?
When the child is put to bed
In the morning when the child awakens
After toileting
After bathing
29
Before administering Hep B vaccine, what type of the allergy should the nurse assess?
Sulfas
Eggs
Baker's yeast
PCN
30
HR110, intermittent grunting w/ resp of 70, flaccid tone, no response to stimuli, overall pale
6
2
3
4
31
How is iron deficient anemia related to infections in children?
More susceptible to infection
Little is known about correlation
Equally susceptible to infection
Less susceptible to infection
32
What would alert the nurse the most in a pt with an descended testis?
Poor weight gain
Abnormal lower extremity reflexes
A history of frequent emesis
A bulging in the inguinal area
33
A pt needs further teaching when she states that carrying twins puts her at risk for?
Anemia
Preterm labor
Group B Streptococcus
Twin to twin transfusion
34
How would the nurse explain the need of AquaMEPHYTON to the mother of a newborn?
It's Vitamin K a water soluble vitamin deficient in newborns
Supplies Vitamin K, which they cannot make initially
It will treat hemorrhagic disease of the new born
Multivitamin that has many effects, including prothrombin
35
What is proper D/C teaching in a client dx with poststreptococcal glomerulonephritis?
Monitoring pulse rate and rhythm
Preventing respiratory infections
Restricting foods high in potassium
Restricting dietary protein
36
A parent of an 8mo should be referred to a doctor if the child is unable to
Sit without support for long periods of time
Stoop to recover an object
Stand alone well for long periods of time
Stand momentarily without holding onto furniture
37
A pt with anorexia is taking diet pills instead of complying with diet. What should the RN do?
Talk w/ client about how weight loss and emaciation worry Dr
Listen to the client about fears of losing control of eating
Ask family about their worries regarding pts health
Explain to client how diet pills can jeopardize health
38
What is the cause of the "red brick dust" in the newborn's diaper?
Excess iron in the urine
Mucus and urate in the urine
Bilirubin in the urine
Uric acid crystals in the urine
39
Why is the child with leukemia at higher risk for infection?
Vit C intake is reduced over time
Play activities are too strenuous
RBC numbers are inadequate for carrying oxygen
Immature WBCs are incapable of handling infectious process
40
What would indicate a need for further assessment on an initial prenatal visit?
Occasional use of OTC pain relievers
Maternal age of 30 years
H/o diabetes for 6 years
Exercise 3 times a week
41
What activities should a child with a seizure disorder avoid during summer camp?
Hiking
Rock climbing
Swimming
Tennis
42
Why does a sickle cell crisis cause local tissue damage?
Autoimmune reaction complicated by hypoxia
Obstruction to circulation
Lack of oxygen in the red blood cells
Elevated serum bilirubin levels
43
What is top priority nursing action with an epidural?
Monitoring maternal BP for hypotension
Position mother flat in bed to avoid postspinal headache
Tell mother she will feel the need to void more frequently
Checking uterine contractions for increase in strength
44
What should be included in D/C teaching for a child that just had tubes placed?
Admin prescribed ATB while tubes are in place
Blow nose forcibly during a cold
Disregard any drainage from the ear after 1 week
Insert ear plugs when child bathes
45
What intervention should be included when teaching the mother how to breast feed?
Wash nipples with soap and water BID
Supplement the baby with formula until milk is established
Slide finger into baby's mouth to break suction
Begin nursing with the right breast easch feeding
46
What medication needs to be on hand with a pt that has an epidural?
Demerol
Hemabate
Narcan
Celestone
47
Most accurate determination of fluid resuscitation in a child with burn shock?
Skin turgor
Neurological assessment
Adequacy of peripheral pulses
Level of edema at burn site
48
What goal should try to be established in a child with Down syndrome?
Encourage more lenient behavior limits for the child
Teaching the child something new each day
Encouraging self care skills in the child
Achieving age appropriate social skills
49
What nursing actions take priority with a suspected ectopic pregnancy?
Providing emotional support
Administering oxygen
Monitoring vital signs
Obtaining surgical consent
50
37wks gestation infant delivered c-section d/t placenta previa. What will the nurse do first?
Aspirate mucus from mouth with bulb syringe
Stimulate neonate to cry vigorously
Begin resuscitation procedures with bag and mask
Hold neonate upright for mother to view
51
A child who has been sexually abused is having problems communicating. What should the nurse do
Role plaing
Engage in play therapy
Report the abuse to a prosecutor
Give the child's drawings to the abuser
52
Which is true about a vasectomy?
It only requires a yearly follow up once procedure is final
It is easily reversed if children are desired in the future
Another method of protection is needed until a sperm count 0
It is contraindicated in males with cardiac disease
53
What is the best way to help prevent spread of diarrhea among children?
Maintaining frequent hand washing
Limiting play time
No contact with others
Washing all toys
54
What should the nurse expect to do first after a child has ingested unk amt of drain cleaner?
Perform gastric lavage
Insert foley catheter
Administer an emetic
Prepare for tracheostomy
55
A child with sickle cell has a family skiing trip planned. What will the nurse tell parents?
Encourage them to go on the trip
Go on the trip, find a sitter for the sickle cell child
Suggest trip be postponed until next year
Explain that high altitude may cause a sickle cell crisis
56
What is the nurse's first action with a child admitted to the hosp w/ a probable brain tumor?
Introducing child to other pt's of the same age
Eliminate the child's anxiety
Prepare the child and parents for diagnostic procedures
Implementing seizure precautions
57
What should the nurse tell the parents about their 18yo and the meningococcal vaccine?
It is recommended and given in a series of 3 injections
Review the records, it may have already been given
It is highly recommended but a pregnancy screening is needed
It is only necessary if she will be living in a dorm
58
Cerebral palsy is defined as impaired movement resulting from which of the following?
Non progressive brain damage caused by injury
Inflammatory brain disease caused by metabolic imbalances
Malformed blood vessels in ventricles from inheritance
Injury to cerebrum from viral infection
59
How should the child be placed with burns from the waist down?
Ensuring application of leg splints
Flexing hips and knees
In a position of comfort
Lying on abdomen
60
The father of a stillborn baby wants to hold the child. How should the nurse respond?
Give him photographs you took instead
Tell him it would be better not to
Encourage him to discuss it with his wife first
Dress infant in a tshirt and diaper and let him hold it
61
What indicated need for further teaching in a parent with a child with burns and poor appetite
Deciding that she will feed the child herself
Withholding treats and desserts unless meals are eaten
Offering child finger foods that the child likes
Serving smaller more frequent meals
62
What assessment finding is expected in the acute stage of Kawasaki disease?
Cracked lips
A normal appearance
Desquamation of the skin
Conjuctival hyperemia
63
What should the nurse advise the mother to do after redness/swelling at vaccine injection site?
Apply ice pack to injection site
Apply warm pack to injection site
Monitor the infant for fever
Bring infant back to clinic
64
The nurse would expect to observe which of the following in a child with autism?
Lack of social interactions
Normal verbal but abnormal nonverbal communication
Normal responses to sensory stimuli
Normal social play
65
What statement indicates need for further teaching about digoxin administration in a child?
If more than one dose is missed I'll call the Dr
I will not mix meds with food
I will take my child's pulse before giving the med
If my child vomits after admin I will repeat the dose
66
What should the nurse do when a fussy toddler will not take their oral medication in the hosp?
Get another nurse to help hold the pt
Ask for order change to IM or rectal
Allow the parent to give it
Hold dose until later
67
What is a contraindication for conducting a contraction stress test?
Pregnancy at 42 wks gestation
Intrauterine growth restriction
Diabetes mellitus
Marginal abruptio placentae
68
What in the child's chart would make the nurse question giving a child an MMR vaccine?
Anaphylactic reaction to neomycin
Frequent respiratory infections
Local reaction at site of injection of previous MMR
Recent recovery from a cold
69
What should be prepared to be administered in magnesium toxicity?
Potassium chloride
Calcium gluconate
Epinephrine
Oxygen
70
What is crucial info to find out in a family where abuse is suspected?
Type and extent of abuse occuring in family
If the client wants to be separated from her husband
Potential of immediate damage to mother and children
Resources available to the client
71
What is a common parental indicator for parents that abuse their children?
Loss of emotional family attachments
Low self esteem
Unemployment
Lower socioeconomic group
72
How do you know tx for fluid retention w/ nephrotic syndrome is effective?
Decreased abdominal girth
Increased caloric intake
Decreased heart rate
Increased respiratory rate
73
A child has leukemia, what warrants immediate nursing intervention?
Fatigue and anorexia
Swollen neck lymph glands and lethargy
Enlarged liver and spleen
Fever and petechia
74
A multigravida client in active labor has variable decels at 100-110. ext action?
Reposition client and continue to evaluate
Perform a vaginal exam
Administer oxygen via face mask at 2L/m
Notify dr of decels
75
Parents of a pt with a myelomeningocele see their baby for the first time. Nurse's response?
Emphasizing infant's normal and positive features
Encourage parents to discuss fears and concerns
Have the parents feed their infant
Reinforce doctor's explanation of the defect
76
What should be included in the teaching plan for a child dx with scoliosis wearing a brace?
Wear the brace during waking hours
Bathe the skin under the brace once per week
Wear a form fitting sleeveless t shirt under the brace
Use lotions to relieve skin irritations
77
How does the nurse prevent heatloss from the 36k gestation infant?
Keep neonate away from air conditioning vents
Dry the neonate after delivery
Place neonate away from outside windows
Prewarm the bed
78
2yo with 35% partial and full thickness burns, what is the priority nursing intervention?
Sedating with morphine
Inserting NG tube
Restricting IV fluids
Inserting Foley catheter
79
What is the first action to take after a ventriculoperitoneal shunt?
Administer narcotics for pain control
Test cerebrospinal fluid leakage for protein
Check urine for glucose and protein
Monitoring for increased temperature
80
What needs to be included in teaching for Dilantin in a child with a seizure disorder?
Having someone be with the child during waking hours
Drinking plenty of fluids
Reporting signs of infection
Brushing teeth after each meal
81
6mo dx with hypospadias sent home with stent. What should the nurse instruct the parents to do?
Avoid tub baths until stent is removed
Measure output in the urinary bag
Clean tip of penis with soap and water three times a day
Avoid drinking fruit juice
82
What is most appropriate for a school age child combative at dressing changing times for burns?
Give child permission to cry during procedure
Ensure parental support during dressing changes
Allow child to schedule time of dressing changes
Allow child to assist in removing dressings
83
What should the nurse do first for a 21mo who is irritable with HR120, resp48, temp100.8F?
Allow toddler to continue to try
Notify DR immediately
Offer clear fluids every few minutes
Administer Tylenol
84
A nurse noted that the HepB vaccine that is going to be administered is cloudy. What next?
Calculate pediatric dosage since it is intended for adults
Discard the vaccine and contact the supplier
Shake vial gently and draw up vaccine
Run under warm water
85
A child with measles should be on what type of precautions?
Contact
Enteric
Respiratory
Protective
86
What needs to be assessed before giving IV magnesium sulfate?
Urinary output, respirations, patellar reflexes
Temperature, blood pressure, respirations
LOC, funduscopic appearance, knee reflex
Urinary glucose, acetone, specific gravity
87
Before advising a pt about oral contraceptives, what should the nurse assess for?
Acne
Dysmenorrhea
Anemia
Hypertension
88
What is not a side effect of oral contraceptives?
Headache
Weight gain
Nausea
Ovarian cancer
89
Additional teaching is needed when parents of a baby with clubfoot with a cast state:
I should use a pillow to elevate child's foot as he sleeps
My baby will need a series of casts to fix her foot
I should call if I see changes in the color of the toes
Having a cast should not prevent me from holding my baby
90
What is not a realistic expected outcome for a child that is mentally retarded?
IQ below 70
Normal intellectual capacity
Difficulty learning
Deficits in adaptive behavior
91
Clear drainage is found on bed linens in a child that had craniotomy for brain tumor. Next?
Notify the physician
Test the fluid for glucose
Change the dressing
Elevate the head of the bed
92
A child at a school party with a known food allergy c/o itchy throat and wheezing. First action
Assess vital signs
Send someone to activate emergency response system
Position to facilitate breathing
Administer child's Epi
93
A teen girl is given amoxicillin for ear infection. What should the nurse advise risks with?
Oral contraceptives
Antacids
Protein shakes
Multiple vitamins
94
What assessment finding would delay admin of the DTaP vaccine in a 6 month old?
An acute bilateral ear infection
A fever of 101.3 following 4 month vaccines
A family history of SIDS
Living with a family member that is immunosuppressed
95
A pt is dx with premature ROM at 36wks. What order would the nurse expect?
Frequent assessment if cervical dilation
IV oxytocin administration
Sonogram for amniotic fluid volume index
Vaginal culture for Neisseria gonorrhoeae
96
A contraindication in a child receiving vaccines is
Otitis media
A cold
Mild diarrhea
A severe febrile illness
97
How should the pinna be pulled when instilling ear drops in a 2yo child's ears?
Down and forward
Up and forward
Down and backward
Up and backward
98
What illness history suggest that a child may have pneumococcal meningitis?
Fractured clavical
Septic arthritis
Middle ear infection
Bladder infection
99
A client with a myelomeningocele is experiencing increased intracranial pressure when the child
Has a high pitched cry
Has overflow voiding only
Has minimal lower extremity movement
Has a fontanel that bulges with crying only
100
What is not an adverse affect of preeclampsia on growing fetus?
Poor placental perfusion
Hydrocephalic infant
Abruptio placentae
Intrauterine growth retardation
101
What should included in plan of care for a primigravid full term client in active labor?
Supine positioning on back if it is comfortable
Pain level assessment every 30 minutes
Vaginal bleeding and ROM assessment every shift
Oxygen saturation monitoring every half hour
102
Myelomeningocele is commonly associated with?
Excessive cerebrospinal fluid within the cranial cavity
Congenital absence of the cranial vault
Abnormally small head
Overriding of the cranial sutures
103
What is the most therapeutic response to a teen that has compulsive eating disorder?
Everyone who has the same problem feels like you do
Tell me more about your feelings
Don't worry, you'll soon be back in shape
I don't think you look bad at all
104
A nurse explains that a heart cath for a child w/ a ventral septal defect involves what?
Catheter placed in the right femoral vein
Ultra high frequency sound waves
General anesthesia
Cut down procedure to place the catheter
105
What is correct teaching info for admin of iron supplements to the child with anemia?
Increase dietary intake of iron fortified foods
Admin will be with meals
Reporting of dark stools
Admin will be in combination with fruit juices
106
Full thickness burn includes damage to what level?
Dermis
Epidermis
Bone
Subcutaneous tissue
107
A client with no prenatal care is about to deliver her baby. What should the nurse assess first
Estimated date of delivery
Gravida and parity
Amniotic fluid status
Prenatal history
108
What lab results does the nurse need to review with a mother Rh negative and baby Rh positive?
Hemoglobin
Bilirubin
Indirect Coombs
Direct Coombs
109
41wk neonate is on mechanical vent for meconium aspiration. What care should the nurse include?
Care of umbilical arterial line
Frequent ultrasound scans
Orogastric feedings as soon as possible
Assessment for s/s of hyperglycemia
110
What assessment finding in a child with CHF alerts the nurse that they may be in fluid overload
Diaphoresis
Weight gain of 1 lb in 1 day
Bradypnea
Decreased blood pressure
111
What is the most appropriate discipline instruction for a toddler?
Reasoning
Spanking
Time out
Structured interactions
112
Propping the bottle when feeding the neonate can lead to what?
SIDS
Tooth decay in the formative months
Aspiration of the formula
Overfeeding and obesity
113
What is most appropriate teaching in a birthing class for first trimester mothers?
Choosing a prenatal care providor
Post partum self care
Care of the newborn infant
Breathing techniques for pain relief in labor
114
An 18mo is admitted with an URI. The nurse observes the pt tripoding. What first?
Call the rapid response team
Offer the child a carbonated drink
Position the child supine
Place the child in a croup tent
115
What is not included in determining normal blood pressure range for a child?
Height
Age
BMI
Gender
116
What should the nurse expect to see in a child with meningitis and DIC?
Cyanosis
Edema
Hemorrhagic skin rash
Dyspnea on exertion
117
Before placement of a ventricloperitoneal shunt, what would best maintain nutritional status?
Scheduling the feeding every 6 hours
Giving the infant small, frequent feedings
Feeding infant just before doing any procedures
Feeding the infant in a horizontal position
118
What should be included in plan of care for a pt dx with rheumatic fever and carditis in hosp?
Ensure continuous parental presence a the child's bedside
Encourage participation in age appropriate activities
Advise child to eat as much as possible
Providing the child with periods of rest
119
A 6hr old infant passes unformed, black, tarlike stool. The nurse concludes that this is a
Meconium stool expected at this time
Transitional stool expected at this time
Transitional stool expected later
Meconium stool expected at time of birth
120
What will be included in teaching to parents of a child dx w/ juvenile idiopathic arthritis?
Many affected kids have remissions but severe deformities
Most affected children recover completely within a few years
Half of affected children recover without joint deformity
Disease usually progresses to crippling rheumatoid arthritis
121
Which is the appropriate language development for a 8 month old?
Saying ball when parents point to a ball
Saying dada and mama to parents specifically
Saying dada and mama non specifically
Saying three other words besides dada and mama
122
What can gonorrhea cause in the neonate?
Eye infections
Congentital anomalies
Perineal discharge
Liver damage
123
How would the nurse respond when a parent asks how her child got pinworms?
Hands
Food
Toilet seats
Animals
124
A child with a brain tumor is less responsive. What should the nurse do?
Notify the physician
Obtain an oximeter reading
Administer an analgesic
Rasie the head of the bed
125
What suggests to the nurse the child may have celiac disease?
Short in height
Stools large and smelly
Dark urine
Small abdomen
126
What teaching is appropriate when caring for a child with mono?
Maintain the child on bed rest for 2 weeks
Notify Dr if child develops abdominal or left shoulder pain
Maintain respiratory precautions for 1 week
Notify Dr if the child develops a fever
127
Why are children sensitive when it comes to fluid and electrolyte balance?
It is harder to tell when they are dehydrated
Immature kidneys
They don't drink as much as adults
They cannot be rehydrated as quickly
128
In a pt trying to become pregnant, what statement indicated need for further teaching?
Intercourse every other day the wk before & after ovulation
Have intercourse on 14th day of menstrual cycle
Abstain from intercourse 1 month prior to conception month
Have intercourse when basal body temp rises
129
At what age should a child be able to brush their teeth without help?
3
7
5
9
130
What assessment technique should the nurse try first with an uncooperative 2 year old?
Ask another nurse to assist
Restrain the child's arms
Allow a parent to assist
Wait until the child calms down
131
How should the nurse explain the need for a HPV vaccine to the parents of a 12 year old?
If she is sexually assaulted she will be exposed to HPV
Parents are never sure when their child is sexually active
HPV is most common in teens and women in early twenties
Most effective against cervical ca before sexual activity
132
How should the child be placed after a moderate head injury?
Semi Fowler's with arms at side
Lying on back in Trendelenburg
Lying on side with head of bed elevated
Prone with hips and knees elevated
133
A 2yo should be able to do which of the following?
Tie his shoelaces
Use blunt scissors
Kick a ball forward
Ride a tricycle
134
What is an example of secondary prevention in community health?
Pallitive care
Rehabilitation
Screenings
Hand washing
135
A child finishes ATBs for ear infection, but is not better. What should the nurse do?
Tell mom ATBs will probably be repeated
Suggest decongestant for the child
Report assessment to PCP and explain probability of more ATB
Suggest child seen ear, nose and throat Dr
136
What is the most important assessment in a pt in the forth stage of labor?
Maternal emotional status, infant bonding, feeding
Ability to push, hydration, and emotional stability
Maternal VS, fetal heart tones, contraction pattern
Maternal VS, fundus, bladder, lochia
137
A breastfeeding pt w/ an episiotomy is prescribed Motrin. When should she be advised to take it
Beofre going to bed
When providing supplemental formula
Immediately after a feeding
Midway between feedings
138
An ill child says he's afraid to sleep b/c the monsters will get him. What will be suggested?
Allow him to sleep w/ parents whenever he's afraid
Read him a story and allow a cuddly animal or blanket
Increase activity before bed so that he is tired
Allow him to stay up an hr later with the family
139
What is a priority nursing goal when caring for a client in complicated labor?
Ensure that the client knows what to expect
Prevent fear and anxiety
Establish a trusting relationship
Prevent invasion of privacy
140
What is a long term goal for a teen dx with bulimia?
Being able to attend college without bingeing or purging
Eat meals at home without bingeing or purging
Being able to eat out without bingeing or purging
Managing stressors in life without bingeing or purging
141
How should the nurse instruct the mother about how a preschooler perceives illness?
A punishment for wrong doing
A necessary part of life
The will of God
A test of self worth
142
How should a nurse respond to a mother upset by her child being called mentally retarded?
I'm sorry I offended you by my thoughtless remark
Retarded is the most commonly used and accepted term
I'd like to hear more of thoughts and feelings about that
No matter what it's called the condition is the same, right?
143
What plan of care is most appropriate for a baby with an HIV positive mother?
Administer zidovudine after delivery
Cuddle the baby as much as possible
Place the baby's crib in a quiet corner of the nursery
Encourage the mother to breast feed
144
What should be noted in the initial assessment of a newborn's history?
Mother's age is 14
Mother drinks a glass of wine with dinner each night
Mother's blood type is O negative
Mother received Demerol before delivery
145
What is most appropriate to institute when a 3yo with meningitis is restless and irritable?
Limiting conversations with child
Performing treatments quickly
Keeping extraneous noises to a minimum
Allowing child to play in the bathtub
146
What is proper instruction to a parent of a child with hemophilia that is beginning to crawl?
Sew thick padding into elbows and knees of child's clothing
Expect primary teeth coming in to produce moderate bleeding
Admin child's aspirin for fever over 101
Check child's urine color daily
147
What would alert the nurse that the child has had a febrile seizure?
Family history is negative for convulsions
Seizure occurred when the child had a respiratory infection
Low grade fever for several weeks
Seizure resulted in respiratory arrest
148
What suggests to the nurse that a 15 month old is being abused?
Child sucks his thumb
Child is underdeveloped for his age
Child appears happy when personnel work with him
Child plays alongside others contently
149
What statement indicates to the nurse that the laboring mother needs further education?
My partner can help me stay relaxed and focused
Because this is my first labor, I will need an epidural
Labor can be long and difficult sometimes
I should keep taking at least ice chip throughout labor
150
An 18mo eats ash, crayons, and paper. What should be assessed first?
Any changes in the home environment
Intake of a soft, low roughage diet
Amount of attention from the mother
Evidence of eruption of large teeth
151
What is priority when preparing a child for corrective surgery of cleft lip?
Alternating the usual method of feeding
Maintaining skin integrity in the oral cavity
Using techniques to minimize crying
Preventing infant from putting fingers in mouth
152
A 5yo screams at mom when she tries to remove bandage from a blood draw "blood will run out"
He does not understand body integrity
He is expressing pain
He fears another procedure
He is attempting to regain control
153
What parental characteristic is least likely to be a risk for child abuse?
Low self esteem
Inadequate knowledge of normal growth & development patterns
Being a member of a large family
History of substance abuse
154
What diet chosen for a child with burns indicates need for further teaching in the parent?
Chix nuggets, orange&grapefruit, vanilla milkshake
Beef, bean, cheese burrito, banana, fruit yogurt, skim milk
Cheeseburger, cottage cheese, pineapple, choc milk, brownie
BLT, milk, celery and carrots
155
What most likely alerts the nurse that placenta previa is present?
Uterine tetany
Dull lower back pain
Painless vaginal bleeding
Intermittent pain with spotting
156
In a child with Down syndrome the nurse should focus on activities to increase what w/ parents
Affection for their child
Understanding of their child's disability
Responsibility for the child's welfare
Confidence in their ability to care for their child
157
A hydrocele is most likely caused by?
Blockage to the inguinal canal that allow fluid accumulation
Patent processus vaginalis that allows fluid accumulation
An obliterated processus vaginalis that allows fluid accumul
Failure of the upper part of processus vaginalis to atrophy
158
After a pt is informed she is preg, she states Is it really true?I can't believe it!" Response?
Yes it is, how does that make you feel?
You should be delighted you are pregnant!
Weren't you and your husband trying to have a baby?
Would you like books on the pregnancy experience?
159
A nurse explains to the pt that the child that is 50% for height and 45% for weight means that
Overweight for height
Average height and weight
Underweight for height
Abnormal in height
160
In what time frame is the child at greatest risk for postop hemorrhage after tonsillectomy?
1 to 3 days
7 to 10 days
4 to 6 days
11 to 14 days
161
What clothing item could promote a potential problem for the postpartum client?
Colored tights
Short athletic socks
Pantyhose
Knee-highs
162
How should the RN approach a toddler for the first time that is about to have tubes inserted?
Pick up toddler and take to play room so mom can relax
Hold the toddler so that they become more comfortable
Walk over and pick up toddler right away so mom can relax
Talk to the mother first so the child gets used to the RN
163
The nurse should address which concern in the adolescent client preparing to deliver?
Reliability of her boyfriend as a support person
Pregnant adolescent's nutritional needs
Appropriateness of names she has chosen for the baby
Misconceptions of the functions of various body parts
164
What is most appropriate when assessing pain in a toddler?
Ask the child about the pain
Use a pain numeric scale
Assess for change in vital signs
Observe the child for retlessness
165
What is an example of primary prevention in community health?
Proper food prep
Mammogram
Prevention of compliations
Early detection of disease
166
What does the umbilical cord contain?
2 arteries, 1 vein
1 artery, 1 vein
1 artery, 2 veins
2 arteries, 2 veins
167
Aspirin in contraindicated in the child dx with rheumatic fever with what other s/s?
Facial edema
Arthralgia
Joint pain
Viral infection
168
How will the nurse know magnesium sulfate has been effective in the pregnant client?
Serum mag level reached 2.2
There is an absence of seizure activity
BP has stabilized at 128/76
Contractions are steady at every 4 minutes
169
What is true about an IUD used for family planning?
Amenorrhea is a common side effect
IUDs are more costly than other forms of contraception
Additional protection needs to be used
Severe cramping may occur when IUD in inserted
170
What assessment question needs asked to a child with possible rheumatic fever?
Any nausea or vomiting?
Any sore throat or unexplained fever in last 2 months?
Any complaints of headaches?
Any complaints of back pain?
171
What are signs of magnesium sulfate toxicity?
Increase in respiratory rate
Development of seizures
Increase in blood pressure
Disappearance of knee-jerk reflex
172
What is the best way for a mother with a neonate in the ICU to soothe a fussy infant is?
Stroke the neonate's back
Place a music mobile over the crib
Bring in toys for distraction
Use constant, gentle touch
173
How should you position a neonate with an unrepaired myelomeningocele?
Supine in semi-fowlers with chest and abdomen elevated
Supine with hips at 90 degree flexion
Prone with hips in abduction
Ride side lying position with knees flexed
174
Which pt is at greatest risk for early post partum hemorrhage?
A pt with a baby weighing 5 lb 7 oz
A pt with uterine atony
A pt that is 17 yrs old
A pt with endometriosis
175
A potty trained 3yo is wetting the bed while in the hosp. What should the nurse tell the mother
It's common for children to regress when they're in the hosp
Children are afraid in the hosp and frequently wet the bed
This is normal, he probably got too much fluid
He's too immature to be potty trained
176
What is the next step when you find that a fundus is firm and displaced to the right?
Have client void and reassess
Notify the Dr
Start a pad count
Massage the fundus until firm
177
How will the nurse explain anorexia to a group of young girls?
Obsession with weight of others, chronic dieting
Extreme concern about dieting, calorie counting
Intense fear of obesity, emaciation
Excessive fear of becoming obese, near normal weight
178
A pt dx with preeclampsia begins to have a seizure. What is the nurse's first action?
Turn the pt to her left side
Call for immediate assistance
Insert an airway to improve oxygenation
Note the time when seizure begins and ends
179
What intervention is appropriate in a 10yo with a 4in burn from hot liquid?
Apply cool water to burned area
Keep child warm
Call 911 to transport child to hospital
Cover burned area with antibiotic cream
180
The best indication of how mentally retarded child progressing is by observing him:
At school with his teacher
At home with his family
Playing soccer with his friends
In the clinic with his mother
181
What sign indicates fetal distress?
Meconium stained amniotic fluid
Moderate amount of bloody show
Pink tinged amniotic fluid
Acceleration of fetal heart rate with each contraction
182
What is appropriate when preparing to give ophthalmic erythromycin?
Withhold dose for 2hrs to allow infant-mother bonding
Use tube from previous birth that has only been open 2hrs
Irriaget the eyes after dose to flush out organisms
Administer dose in lower conjuctival sac
183
What food should a nurse recommend for a vegetarian needing to increase her folic acid intake?
Bananas
Apple juice
Hamburger
Peanuts
184
What would estimated due date be when date of last period began on May 10th?
January 17
February 17
January 13
February 13
185
What danger signs should the prenatal pt report to the nurse?
Occasional nausea and vomiting
Dizziness and blurred vision
No bowel movement for 3 days
Ankle edema
186
What type of stools would the nurse expect in a child with colic?
Foul smelling stools
Soft, yellow stools
Frequent watery stools
Ribbon like stools
187
What should not be included in a meal plan with a child with cystic fibrosis?
Fried scallops
Milk shake
Roasted chicken
Egg omlet
188
A mother of a child with a head injury asks how you will know that her child is getting better
Reaction of pupils
Motor strength
The vital signs
Level of consciousness
189
The best indicator that Mannitol has been effective in a child with a head injury is?
Decreased intracranial pressure
Decreased edema
Improved LOC
Increased urine output
190
What muscle is used for IM shots in children and infants?
Ventrogluteal
Deltoid
Dorsal gluteal
Vastus lateralis
191
Lactose intolerance is characterized by what?
Lack of an enzyme to break down lactose
Inability to digest proteins completely
Inability to digest fats completely
Allergy to lactose found in milk
192
What is true about the communicable period with chicken pox?
2 weeks or less to several months
1-2 days before rash, 6 days after first crop of vesicles
10 days before s/s, 15 days after rash appears
It is unknown
193
What is most appropriate for raising IQ in a child with Down syndrome?
Giving vasodilator meds as prescribed
Serving hearty, nutritious meals
Providing stimulating, nonthreatening life experiences
Letting the child play with more able children
194
Nonmodifiable health risks include
Diet
Age
Environmental health
Substance use
195
What is the initial treatment of a child that ingest unk amt of acetaminophen?
Gastric lavage
EKG
Frequent blood level determinations
Tracheostomy
196
What is a sign of a blocked shunt in a toddler?
Irritability and increasing difficulty with eating
Decreased urine output with stable intake
Elevated temperature and reddened inciisional site
Tense fontanel and increased head circumference
197
To encourage autonomy of a 4yo, the nurse should instruct the mother to
Discourage the child's choice of clothing
Button the child's coat and clouse
Praise the child's attempts to dress herself
Tell the child when the combination of clothes is not right
198
After cardiac surg, what statement by mother indicates need for further teaching?
A balance of rest and exercise is important
Large crowds of people need to be avoided for at least 2 wks
I can apply lotion or powder to the incision if it is itchy
Activities with risk of falling need to be avoided 2-4 wks
199
With what assessment finding would Methergine be contraindicated?
BP of 120/60
Heart rate of 60
BP of 140/100
Respiratory rate of 12
200
After c-section a mother wants to breastfeed. What is the most appropriate hold to suggest?
Cross cradle
Football
Scissors
Cradle
