Chapter 22: Health Care Adaptations for the Child and Family Nursing School Test Banks

Chapter 22: Health Care Adaptations for the Child and Family

MULTIPLE CHOICE

1. What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant?
a. Brachial
b. Apical
c. Radial
d. Femoral
ANS: B
Apical pulses are advised for children under age 5 years.

DIF: Cognitive Level: Knowledge REF: Page 491 OBJ: 4
TOP: Physical Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse?
a. Give the medication after confirming the childs name from the foot of the crib.
b. Ask the charge nurse to give the medicine.
c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.
d. Delay the medication until the admissions office can supply a new ID bracelet.
ANS: C
After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

DIF: Cognitive Level: Application REF: Page 486 | Page 507 | Page 513
OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions?
a. I should wash my perineum with soap and water, then begin to urinate.
b. I clean the perineum from front to back with an antiseptic wipe before I urinate.
c. Ill collect the first stream of urine in a sterile container.
d. I will discard the first void and collect a freshly voided specimen 30 minutes later.
ANS: B
To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

DIF: Cognitive Level: Analysis REF: Page 497 OBJ: 2
TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

4. Which strategy might the nurse use when administering oral medications to a young child who is reluctant?
a. Mix the medication with chocolate milk.
b. Tell the child that the medication is candy.
c. Give the medication quickly if the child is crying.
d. Offer the child fruit juice after the medication is swallowed.
ANS: D
The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it.

DIF: Cognitive Level: Application REF: Page 501 OBJ: 2
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. A parent tells the nurse, Im not sure how to give this medicine to my infant. How would the nurse teach the parent to best administer an oral suspension?
a. Pour the medication into a small cup and allowing the infant to drink it.
b. Place the medication in a nipple and having the infant suck the nipple.
c. Use an oral syringe and placing the medication in the side of the infants mouth.
d. Administer the medication with a dropper onto the back of the infants tongue.
ANS: C
An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back, at the side of the mouth.

DIF: Cognitive Level: Application REF: Page 502 OBJ: 10
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops?
a. Up and back
b. Down and back
c. Up and out
d. Down and out
ANS: A
For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

DIF: Cognitive Level: Application REF: Page 503, Skill 22-8
OBJ: 10 TOP: Administering Ear Drops
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. Why is a tympanic thermometer considered more accurate than other types of thermometers?
a. The thermometer probe is blunt and wide.
b. It takes a brief time to register.
c. The tympanic membrane shares circulation with the hypothalamus.
d. The tympanic membrane and the brain have the same temperature.
ANS: C
The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

DIF: Cognitive Level: Knowledge REF: Page 495 OBJ: 4
TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
a. Discard the residual and increase the volume of feeding by the amount of residual.
b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
c. Refill the syringe with formula after it has completely emptied.
d. Position the child on the right side after a feeding.
ANS: D
To prevent regurgitation and aspiration, the child is placed in the Fowlers position or on the right side to promote gastric emptying after a gastrostomy tube feeding.

DIF: Cognitive Level: Application REF: Page 515, Skill 22-10
OBJ: 13 TOP: Enteral Feedings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

9. Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?
a. Mummy
b. Clove hitch
c. Jacket
d. Elbow
ANS: A
A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

DIF: Cognitive Level: Comprehension REF: Page 488 | Page 489, Skill 22-1
OBJ: 12 TOP: Restraining the Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

10. How often should a child who has a continuous intravenous infusion should be assessed?
a. Hourly
b. Every 2 hours
c. Every 3 hours
d. Every 4 hours
ANS: A
The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

DIF: Cognitive Level: Knowledge REF: Page 505 OBJ: 12
TOP: Administering Parenteral Medications
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

11. The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide?
a. 1.25
b. 1.4
c. 1.6
d. 1.8
ANS: B
600,000_mL
5 mL 150,000 = 1.25 mL

This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant.

DIF: Cognitive Level: Analysis REF: Page 509, Medication Safety Alert
OBJ: 9 TOP: Administering Injections
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. Which intervention will the nurse implement when suctioning a tracheostomy?
a. Suction for two to three breaths.
b. Clear the catheter with water after suctioning for reuse.
c. Apply suction for no more than 15 seconds.
d. Establish a regular schedule for suctioning.
ANS: C
Suctioning should be limited to 15 seconds.

DIF: Cognitive Level: Application REF: Page 516 OBJ: 15
TOP: Respiration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

13. What emergency action should be implemented for airway obstruction in the infant?
a. Six to 10 midsternal thrusts
b. Five back blows followed by five chest thrusts
c. Five chest thrusts followed by five back blows
d. Abdominal thrusts until the object is expelled
ANS: B
Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

DIF: Cognitive Level: Knowledge REF: Page 519 OBJ: 2
TOP: Management of Airway Obstruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

14. A 4-year-old asks tearfully if the IM injection will hurt. What is the nurses most effective response?
a. No. It is over before you know it.
b. Yes. It will sting a little.
c. No. Would you like to see the syringe?
d. Yes. Your mom and I are going to hold you to help you be still.
ANS: B
Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

DIF: Cognitive Level: Application REF: Page 504 OBJ: N/A
TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

15. Where is the best site for giving an IM injection to a 15-month-old child?
a. Ventrogluteal muscle
b. Dorsogluteal muscle
c. Deltoid muscle
d. Vastus lateralis muscle
ANS: D
The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

DIF: Cognitive Level: Application REF: Page 503 OBJ: 11
TOP: Administering Injections KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. What factor does the nurse explain affects the infants physiological response to medications?
a. Faster metabolism in the liver
b. Slower intestinal transit
c. Immature kidney function
d. Increased secretion of hydrochloric acid
ANS: C
Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

DIF: Cognitive Level: Comprehension REF: Page 500 OBJ: N/A
TOP: Physiological Responses to Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

17. What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant?
a. Diaper the infant snugly with a disposable diaper.
b. Cover the area with a transparent dressing.
c. Apply a cloth diaper.
d. Place the infant on a plastic pad, undiapered.
ANS: C
Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

DIF: Cognitive Level: Application REF: Page 500 OBJ: 2
TOP: Rapid Absorption of Drug KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

18. Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury?
a. The blanket is not tucked into the mattress.
b. Diapers and wipes are stacked at the foot of the crib.
c. The crib side is locked in the up position.
d. Pillows are stacked on the bedside table.
ANS: B
Disposable diapers and supplies must be kept out of the infants reach to prevent accidental suffocation.

DIF: Cognitive Level: Analysis REF: Page 487-488
OBJ: 2 TOP: Essential Safety Measures
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

19. A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure?
a. On your stomach with your head turned to the side.
b. On your side, keeping the legs bent and the head arched back.
c. On your back with your legs extended straight out.
d. On your side with the knees bent and the head close to the knees.
ANS: D
The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

DIF: Cognitive Level: Application REF: Page 499, Figure 22-7 A
OBJ: 8 TOP: Collecting SpecimensLumbar Puncture
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

20. The nurse is caring for a 4-year-old child. What will the nurse expect the childs daily urinary output to be?
a. 400 to 500 mL
b. 500 to 600 mL
c. 600 to 700 mL
d. 700 to 1000 mL
ANS: C
The average daily excretion of urine for a 4-year-old child is 600 to 700 mL.

DIF: Cognitive Level: Knowledge REF: Page 499, Table 22-4
OBJ: 4 TOP: Collecting SpecimensUrine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the infants urine output?
a. 47 mL
b. 44.5 mL
c. 43.5 mL
d. 40.5 mL
ANS: B
Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 2.5 = 44.5 grams = 44.5 mL of urine.

DIF: Cognitive Level: Analysis REF: Page 513, Nursing Tip
OBJ: 4 TOP: Collecting SpecimensUrine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

22. The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse?
a. Red meat
b. Green, leafy vegetables
c. Acidic fruit juices
d. Egg yolks
ANS: D
Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

DIF: Cognitive Level: Application REF: Page 514, Table 22-8
OBJ: 2 TOP: Food/Drug Interactions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

23. The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention?
a. Toddler with an axillary temperature of 99 F
b. School-age child with widening pulse pressure
c. Infant pulse rate of 100 beats per minute
d. Adolescent with a respiratory rate of 28 breaths per minute
ANS: B
A widening pulse pressure can indicate increased ICP; therefore it is the priority. An axillary temperature of 99 F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.

DIF: Cognitive Level: Application REF: Page 491-492
OBJ: 5 TOP: Vital signs KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

24. A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient?
a. Left side-lying
b. Supine
c. Prone
d. Semi-Fowlers
ANS: B
The adolescent may avoid postlumbar puncture headache by lying flat for some time.

DIF: Cognitive Level: Application REF: Page 499 OBJ: 2
TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

MULTIPLE RESPONSE

25. Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.)
a. Purpose of the procedure
b. Risks associated with the procedure
c. That no suit can be brought for damages
d. That the document must be signed and witnessed
e. That information was given
ANS: A, B, D, E
The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

DIF: Cognitive Level: Comprehension REF: Page 486 OBJ: 4
TOP: Informed Consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

26. Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.)
a. Insulin
b. Digoxin
c. Vasodilators
d. Calcium salts
e. Anticoagulants
ANS: A, B, D, E
Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration.

DIF: Cognitive Level: Comprehension REF: Page 507 OBJ: 2
TOP: Drug Administration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

27. A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse implement? (Select all that apply.)
a. Assess rectal temperature every 4 hours.
b. Administer Acetaminophen as ordered.
c. Assess skin turgor.
d. Restrict fluids.
e. Assess level of consciousness.
ANS: B, C, E
When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

DIF: Cognitive Level: Application REF: Page 492 | Page 494
OBJ: 6 TOP: Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

28. What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.)
a. Age
b. Race
c. Vital signs
d. Distance to travel
e. Level of consciousness
ANS: A, D, E
The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

DIF: Cognitive Level: Comprehension REF: Page 488 OBJ: 3
TOP: Modes of Transportation KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

COMPLETION

29. The nurse is searching through several blood pressure cuffs to find a cuff that is the appropriate size for her small patient. The nurse selects a cuff that covers ______ _______ of the patients upper arm.

ANS:
two thirds

No matter the age of the patient, for the blood pressure cuff to provide an accurate reading it should cover two thirds of the upper arm. A smaller cuff will give an inaccurately high reading and a larger cuff will give an inaccurately low reading.

DIF: Cognitive Level: Application REF: Page 492, Medication Safety Alert
OBJ: 4 TOP: Selection of Blood Pressure Cuff
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

30. The nurse is aware that for the 3-month-old who has a surgery time of 2:30 PM, the start order for NPO should be no earlier than ____________________.

ANS:
8:30 AM

Periods of NPO should not exceed 4 to 6 hours for pediatric clients because they can become dehydrated very quickly.

DIF: Cognitive Level: Application REF: Page 509 OBJ: 16
TOP: NPO Orders in Infants KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

31. The order reads, Give ampicillin oral suspension 400 mg PO every day. The vial reads, Ampicillin 125 mg/5 mL. The nurse will give a dose of ______ mL.

ANS: 16

DIF: Cognitive Level: Analysis REF: Page 509 OBJ: 9
TOP: Pediatric Dose Calculation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

32. The physician has ordered phenytoin syrup 20 mg PO bid for a child who weighs 15 pounds. The PDR states that 10 mg/kg/day is the maximum daily dose. The safe daily dose of this medication is _____ mg.

ANS:
34

15 pounds = 6.8 kilograms; 6.8 10 mg = 68 mg maximum daily dose, making the bid doses 34 mg each

DIF: Cognitive Level: Analysis REF: Page 502 OBJ: 9
TOP: Dose Calculation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

33. After instilling nose drops, the nurse will keep the infant in the head down position for at least _________ seconds.

ANS:
30

The retained position for 30 seconds to 1 minute allows the nose drops to enter deeply into the nostril.

DIF: Cognitive Level: Comprehension REF: Page 502, Skill 22-7
OBJ: 10 TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

34. The nurse is aware that because of the function of the mist tent that a child is at risk for ________________.

ANS:
hypothermia

Children in mist tents are at risk for hypothermia because of the high humidity and the cooled oxygen. These children should be dressed warmly and changed frequently. The bed linens should be changed frequently as they absorb moisture from the tent as well.

DIF: Cognitive Level: Comprehension REF: Page 518-519
OBJ: 14 TOP: Mist Tent KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

35. An ________________________ implies that the parent or legal guardian is capable of understanding information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to that procedure.

ANS:
informed consent

An informed consent implies that the parent or legal guardian is capable of understanding information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to that procedure.

DIF: Cognitive Level: Knowledge REF: Page 486 OBJ: 1
TOP: Informed Consent KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

36. When obtaining a urine specimen on an infant, the adhesive of the urine collector is placed between the _____________ and the _________________.

ANS:
anus, perineum

Begin by applying the urine collector to the tiny area of skin between the anus and the perineum. The narrow bridge on the adhesive patch keeps feces from contaminating the specimen and helps to position the collector correctly.

DIF: Cognitive Level: Knowledge REF: Page 498, Skill 22-5
OBJ: 7 TOP: Urine Specimen Collection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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