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1. A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? ANS Administer epinephrine IM Rationale BS When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it causes decreased blood return to the heart. 2. A nurse in a pediatric emergency department is planning care for an ado- lescent. Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take? Select all that apply. BS Apply supplemental oxygen Rationale BMS According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. Also according to the medical record and chest x- 1/34 ray report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia. Therefore, the nurse should plan to administer supplemental oxygen. Prepare for chest tube insertion Rationale BMS According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural cavity, which results in decreased lung expansion. The adolescent could experience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention by the provider, such as the placement of a chest tube into the thoracic cavity to remove air and fluid from the pleural space, if present, allowing the lung to re-expand. 3. A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? BS Monitor the child's oxygen saturation Rationale BMS The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. 4. A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child? MMS Playing dress-up dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? BB Zinc oxide Rationale BMS Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. 8. Anurse is caring for a client who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) ANS First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site. 9. Anurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) BS A 10. A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? WS Screen the child's visitors for indications of infection. Rationale BB A child who is severely inmunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. 11. Anurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following’ instructions should’ the nurse _ include? BMS "Shake the medication prior to administration." Rationale BMS The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. 12. A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? BS "Mononucleosis is caused by an infection with the Epstein-Barr virus." Rationale 15. A charge nurse is preparing to make a room assignment for a newly ad- mitted school-age child. Which of the following considerations is the nurse's priority? BB Disease process Rationale BMS The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. 16. A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the fol- lowing actions should the nurse take prior to the procedure? BMS Administer an analgesic to the child. Rationale ANS Hydrotherapy for debridement of a wound is an extremely painful pro- cedure that requires analgesia and/or sedation. Controlling pain leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder. 17. A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indi- cates an understanding of the teaching? BS "| should keep my child indoors when | mow the yard." Rationale BMS The nurse should instruct the parent to keep the preschooler indoors during 7/34 lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks. 18. A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? BS *% cup raisins Rationale BMS The nurse should encourage the adolescent to eat raisins because they contain the highest amount of non-heme iron. 19. A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? ANS "Encourage the child to perform independent self-care." Rationale BS The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing of lead, especially during renovation, which may aerosolize the lead particles. 22. Anurse in the outpatient pediatric clinic is caring for a 2-year-old child. Drag words from the choices below to fill in each blank in the following sentence. Nurses’ Notes - 2 months ago ANS The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currently being renovated, about 6 months ago. Parent reports having difficulty getting the toddler to Nurses’ N BS When analyzing cues, the nurse should identify that the child is a risk for devel- oping intellectual deficits, such as a decreased IQ, due to the increase in membrane permeability of the brain tissue resulting in increased intracranial pressure, tissue ischemia, and atrophy. The nurse should also identify that the child is at risk for 10/34 decreased kidney function due to the damage of the proximal tubules caused by the elevated blood lead level. 23. The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for the 0800 one month ago visit. Complete the following sentence by using the lists of options. The nurse should first address the child's , followed by the child's Nurses’ Notes - 2 months ago ANS The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports mo BS When prioritizing hypotheses, the nurse should first address the child's elevated BLL, followed by the child's hemoglobin. Using the priority framework of safety and risk reduction, the nurse should recognize that the child's BLL presents an increased risk for long-term cognitive impairment and behavioral issues and should be addressed first. Lead interferes with heme synthesis, which causes anemia, as evidenced by the child's low hemoglobin. Addressing the lead level first will cause the hemoglobin level to improve. Kidney damage (ketonuria and glycosuria) is reversible once the lead level has been addressed. 24. The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for the 0800 one month ago 11/34 finding housing until the renovations are completed and to identify other needed resources. The nurse should anticipate consulting a dietitian to assist the parent in providing meals that are high in iron and calcium and low in fat. These foods are important for the child to consume to diminish the effects of lead poisoning. Chelating agents, such as succimer, are eliminated from the body through the kidneys. It is necessary that the child remains well hydrated during ch 25. The nurse has reviewed the provider prescriptions for the 0900, 1 month ago visit. The nurse is providing discharge teaching to the parent. Which of the following information should the nurse include? Select all that apply. Nurses’ Notes - 2 months ago ANS The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currently being renovated, about 6 months ago. P BS When taking action, the nurse should include in the discharge teaching to open the succimer capsule and sprinkle on 1 tsp of applesauce. A 2-year-old child is unable to swallow a capsule, and this capsule is not an extended- or time-release capsule. Therefore, opening the capsule and sprinkling the contents onasmall amount (1 teaspoon) of pleasurable food will assist in the administration of the medication. A wet cloth should be used to dust. This prevents the spread of lead-containing particles. The parent should give the ferrous sulfate elixir using a straw to prevent staining of the teeth. Offering orange juice or a drink containing high levels of ascorbic acid when administering ferrous sulfate can increase the 13/34 absorption of iron. The parent should monitor the number of wet diapers. It is important that the child stay hydrated during treatment with succimer to prevent renal toxicity. The parent should prevent the child from playing in soil near the house, which most likely is con 26. The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for today's visit. Which of the following conditions are improving since the child's visit 1 month ago? Select 4 of the following conditions. Nurses’ Notes - 2 months ago ANS The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currentl BS When evaluating outcomes, the nurse should identify an improvement in the child's health based on the findings of lead poisoning, kidney function, exposure to lead, and nutritional status. The BLL 14134 Graphic Re BMS Withhold the measles, mumps, and rubella (MMR) vaccine. Rationale BINS The nurse should recognize that an allergy to neomycin with an anaphy- lactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. 29. A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? BMS Initiate lV access Rationale ANS After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. 16 / 34 30. A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? BS Serum creatinine 3.0 mg/dL Rationale BS Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. 31. A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? BS Sched- ule the toddler for a yearly re-screening. Rationale BMS The nurse should schedule the toddler for a lead level re-screening in 1 year and educate the family on ways to prevent exposure. 32. A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (You will find "hot spots” to select in the artwork below. Select only the hot spot that corresponds to your answer.) | Rationale 17134 35. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? BS Serum potassium level 4.1 mEq/L Rationale WMS The nurse should monitor the adolescent's serum potassium level follow- ing the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. 36. A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? ANS Initiate droplet precautions for the child. Rationale BMS The nurse should initiate droplet precautions for a child who has pertus- sis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks. 37. Anurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? BS "| will monitor my child's number of wet diapers." Rationale 19/34 BMS The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. 38. A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? BS Sodium 155 mEq/L Rationale oN child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Under- excretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. 39. Anurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? WB Assess peripheral pulses once every 4 hr. Rationale BS Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks 20/34 
