Chapter 39: Pediatric Variations of Nursing Interventions Nursing School Test Banks

Chapter 39: Pediatric Variations of Nursing Interventions

MULTIPLE CHOICE

1. What should the nurse consider when having consent forms signed for surgery and procedures on children?

a.

Only a parent or legal guardian can give consent.

b.

The person giving consent must be at least 18 years old.

c.

The risks and benefits of a procedure are part of the consent process.

d.

A mental age of 7 years or older is required for a consent to be considered informed.

ANS: C

The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1130

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

2. The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include:

a.

Planning for a short teaching session of about 30 minutes.

b.

Telling the child that procedures are never a form of punishment.

c.

Keeping equipment out of the childs view.

d.

Using correct scientific and medical terminology in explanations.

ANS: B

Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age group should be 10 to 15 minutes in length. Demonstrate the use of equipment and allow the child to play with miniature or actual equipment. Explain the procedure and how it affects the child in simple terms.

PTS: 1 DIF: Cognitive Level: Application REF: 1133

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

3. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to:

a.

Allow her to wear her underpants.

b.

Discuss with her mother why this is important to Katie.

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. This allows her some measure of control during the foot surgery. The mother should not be required to make the child more upset. Katie is too young to understand what hospital policy means.

PTS: 1 DIF: Cognitive Level: Application REF: 1134

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

4. Using knowledge of child development, the best approach when preparing a toddler for a procedure is to:

a.

Avoid asking the child to make choices.

b.

Demonstrate the procedure on a doll.

c.

Plan for the teaching session to last about 20 minutes.

d.

Show necessary equipment without allowing child to handle it.

ANS: B

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.

PTS: 1 DIF: Cognitive Level: Application REF: 1134

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

5. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her like before. The most appropriate nursing action is to:

a.

Grant her request.

b.

Explain why this is not possible.

c.

Identify an appropriate substitute for her mother.

d.

Offer to provide support to her during the procedure.

ANS: A

The parents preferences 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. If the mother and child are agreeable, the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence.

PTS: 1 DIF: Cognitive Level: Application REF: 1138

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

6. The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should:

a.

Ask him to be quieter.

b.

Have his mother tell him to relax.

c.

Tell him it is okay to cry and scream.

d.

Suggest that he talk to his mother instead of crying.

ANS: C

The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know that it is all right to cry. There is no reason for him to be quieter. He is too upset and needs to be able to express his feelings.

PTS: 1 DIF: Cognitive Level: Application REF: 1135

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

7. In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is:

a.

Apnea.

c.

Muscle rigidity.

b.

Bradycardia.

d.

Decreased blood pressure.

ANS: C

Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased, not decreased, blood pressure is characteristic of malignant hyperthermia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1139

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

8. The nurse is caring for an unconscious child. Skin care should include:

a.

Avoiding use of pressure reduction on the bed.

b.

Massaging reddened bony prominences to prevent deep tissue damage.

c.

Using draw sheet to move child in bed to reduce friction and shearing injuries.

d.

Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

ANS: C

A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used to redistribute weight instead. The skin should be cleansed with mild nonalkaline soap or soap-free cleaning agents for routine bathing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1141

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

9. An appropriate intervention to encourage food and fluid intake in a hospitalized child is to:

a.

Force child to eat and drink to combat caloric losses.

b.

Discourage participation in noneating activities until caloric intake is sufficient.

c.

Administer large quantities of flavored fluids at frequent intervals and during meals.

d.

Give high-quality foods and snacks whenever child expresses hunger.

ANS: D

Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the childs hunger and further inhibit food intake.

PTS: 1 DIF: Cognitive Level: Application REF: 1142

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

10. Kimberly, age 3 years, has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102 F even though Kimberly had acetaminophen 2 hours ago. The nurses action should be based on knowing that:

a.

Fevers such as this are common with viral illnesses.

b.

Seizures are common in children when antipyretics are ineffective.

c.

Fever over 102 F indicates greater severity of illness.

d.

Fever over 102 F indicates a probable bacterial infection.

ANS: A

Most fevers are of brief duration, have limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1143

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

11. Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should:

a.

Add isopropyl alcohol to the water.

b.

Direct a fan on the child in the bath.

c.

Stop the bath if the child begins to chill.

d.

Continue the bath for 5 minutes.

ANS: C

Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the bodys way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are inappropriate, potentially dangerous solutions. Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1144

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

12. The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child, the nurse should:

a.

Ask the group, Who is Sam Hart?

b.

Call out to the group, Sam Hart?

c.

Ask each child, Whats your name?

d.

Check the patients identification name band.

ANS: D

The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request; identification bracelets should always be checked. Asking the group to identify the child, calling out the childs name, and asking each child to give his or her name are not acceptable ways to identify a child. Older children may exchange places, give an erroneous name, or choose not to respond to their name as a form of a joke.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1156

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

13. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should:

a.

Wash hands thoroughly.

b.

Check the gloves for leaks.

c.

Rinse gloves in disinfectant solution.

d.

Apply new gloves before touching the next patient.

ANS: A

When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use and hands should be thoroughly washed again before new gloves are applied.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1147

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

14. The nurse gives an injection in a patients room. What should the nurse do with the needle for disposal?

a.

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

b.

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

c.

Cap needle immediately after giving injection and dispose of in proper container.

d.

Cap needle, break from syringe, and dispose of in proper container.

ANS: A

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

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1147

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

15. An 8-month-old infant is restrained to prevent interference with the intravenous infusion. The nurse should:

a.

Remove the restraints once a day to allow movement.

b.

Keep the restraints on constantly.

c.

Keep the restraints secure so the infant remains supine.

d.

Remove the restraints whenever possible.

ANS: D

The nurse should remove the restraints whenever possible. When parents and/or staff are present, the restraints can be removed, and the intravenous site protected. Restraints must be checked and documented every 1 to 2 hours and should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1148

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

16. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this:

a.

Is unsafe.

b.

May help the child relax.

c.

Is against hospital policy.

d.

Is unnecessary because of the childs age.

ANS: B

Both the mothers preference for assisting, observing, or waiting outside the room and the childs preference for parental presence should be assessed. The childs choice should be respected. This will most likely help the child through the procedure. If the mother and child are agreeable, 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1138

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

17. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. The most appropriate way to collect small amounts of urine for these tests is to:

a.

Apply a urine-collection bag to the perineal area.

b.

Tape a small medicine cup to the inside of the diaper.

c.

Aspirate urine from cotton balls inside the diaper with a syringe.

d.

Aspirate urine from a superabsorbent disposable diaper with a syringe.

ANS: C

To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material 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. Taping a small medicine cup to the inside of the diaper is not feasible; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1151

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

18. An important nursing consideration when performing a bladder catheterization on a young boy is to:

a.

Use clean technique, not Standard Precautions.

b.

Insert 2% lidocaine lubricant into the urethra.

c.

Lubricate catheter with water-soluble lubricant such as K-Y Jelly.

d.

Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

ANS: B

The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparing the child and parents, selecting the correct catheter, and using appropriate insertion technique. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and Standard Precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed only 2 to 3 minutes. This provides sufficient local anesthesia for the procedure.

PTS: 1 DIF: Cognitive Level: Application REF: 1153

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

19. What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture?

a.

You must hold still or Ill have someone hold you down. This is not going to hurt.

b.

This will hurt like a pinch. Ill get someone to help hold your arm still so it will be over fast and hurt less.

c.

Be a big boy and hold still. This will be over in just a second.

d.

Im sending your mother out so she wont be scared. You are big, so hold still and this will be over soon.

ANS: B

Honesty is the best approach. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. Telling the child that This will be over in just a second is not supportive or honest. Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so.

PTS: 1 DIF: Cognitive Level: Application REF: 1135

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

20. A nurse must do a venipuncture on a 6-year-old child. An important consideration in providing atraumatic care is to:

a.

Use an 18-gauge needle if possible.

b.

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

c.

Restrain the child only as needed to perform venipuncture safely.

d.

Show the child equipment to be used before procedure.

ANS: C

Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. 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. Keep all equipment out of sight until used.

PTS: 1 DIF: Cognitive Level: Application REF: 1192

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

21. An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with:

a.

A bottle of formula or milk.

b.

Any food the child is going to eat.

c.

A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.

d.

Large amounts of water to dilute medication sufficiently.

ANS: C

Mix the drug with a small amount (about 1 teaspoon) 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/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 in future.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1156

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

22. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration?

a.

Administering the medication with a syringe (without needle) placed along the side of the infants tongue

b.

Administering the medication as rapidly as possible with the infant securely restrained

c.

Mixing the medication with the infants regular formula or juice and administering by bottle

d.

Keeping the child upright with the nasal passages blocked for a minute after administration

ANS: A

Administer the medication with a syringe without needle placed alongside of the infants tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. The child may associate the altered taste with the food and refuse to eat in future. Holding the childs nasal passages increases the risk of aspiration.

PTS: 1 DIF: Cognitive Level: Application REF: 1157

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

23. Guidelines for intramuscular administration of medication in school-age children include to:

a.

Inject medication as rapidly as possible.

b.

Insert the needle quickly, using a dartlike motion.

c.

Penetrate the skin immediately after cleansing the site, before skin has dried.

d.

Have the child stand, if possible, and if he or she is cooperative.

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 skin is penetrated. Place the child in a lying or sitting position.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1162

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

24. When teaching a mother how to administer eyedrops, where should the nurse tell her to place them?

a.

In the conjunctival sac that is formed when the lower lid is pulled down

b.

Carefully under the upper eyelid while it is gently pulled upward

c.

On the sclera while the child looks to the side

d.

Anywhere as long as drops contact the eyes surface

ANS: A

The lower lid 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1169

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

25. A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. What best explains why an intraosseous infusion is started?

a.

It is less painful for small children.

b.

Rapid venous access is not possible.

c.

Antibiotics must be started immediately.

d.

Long-term central venous access is not possible.

ANS: B

In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe lifesaving alternative. The procedure is painful, and local anesthesia and systemic analgesia are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time consuming, and intraosseous infusion is used in an emergency situation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1173

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

26. When caring for a child with an intravenous infusion, the nurse should:

a.

Use a macrodropper to facilitate reaching the prescribed flow rate.

b.

Avoid restraining the child to prevent undue emotional stress.

c.

Change the insertion site every 24 hours.

d.

Observe the insertion site frequently for signs of infiltration.

ANS: D

The nursing responsibility for intravenous therapy is to calculate the amount to be infused in a given length of time, set the infusion rate, and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops per milliliter) is the recommended intravenous tubing in pediatrics. The intravenous site should be protected. This may require soft restraints on the child. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. Frequent change exposes the child to significant trauma.

PTS: 1 DIF: Cognitive Level: Application REF: 1174

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

27. It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible can cause:

a.

Hyperthermia.

c.

Pressure necrosis.

b.

Electrocution.

d.

Burns under sensors.

ANS: D

It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor. Incompatibility would cause a local irritation or burn, not hyperthermia. A low voltage is used, which should not present risk of electrocution. Pressure necrosis can occur from the sensor being attached too tightly, but this is not a problem of incompatibility.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1178

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

28. The nurse is teaching a mother how to perform chest physiotherapy and postural drainage on her 3-year-old child, who has cystic fibrosis. To enable the mother to perform percussion, the nurse should instruct her to:

a.

Cover the skin with a shirt or gown before percussing.

b.

Strike the chest wall with a flat-hand position.

c.

Percuss over the entire trunk anteriorly and posteriorly.

d.

Percuss before positioning for postural drainage.

ANS: A

For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand, position. The procedure should be done over the rib cage only. Positioning precedes the percussion.

PTS: 1 DIF: Cognitive Level: Application REF: 1179

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

29. The nurse must suction a child with a tracheostomy. Interventions should include:

a.

Encouraging the child to cough to raise the secretions before suctioning.

b.

Selecting a catheter with a diameter three-fourths as large as the diameter of the tracheostomy tube.

c.

Ensuring that each pass of the suction catheter take no longer than 5 seconds.

d.

Allowing the child to rest after every 5 times the suction catheter is passed.

ANS: C

Suctioning should require not longer than 5 seconds per pass. Otherwise the airway may be occluded for too long. If the child is able to cough up secretions, suctioning may not be indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it is too large, it might block the childs airway. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1180

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

30. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 mL/8 hr is being infused rather than the ordered amount of 300 mL/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours?

a.

200 mL

c.

350 mL

b.

300 mL

d.

400 mL

ANS: B

The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. The infusion rate should be reset to the prescribed flow rate.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1190

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

31. In preparing to give enemas until clear to a young child, the nurse should select:

a.

Tap water.

c.

Oil retention.

b.

Normal saline.

d.

Fleet solution.

ANS: B

Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the until clear result. Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1190

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

32. What nursing action is appropriate for specimen collection?

a.

Follow sterile technique for specimen collection.

b.

Sterile gloves are worn if the nurse plans to touch the specimen.

c.

Use Standard Precautions when handling body fluids.

d.

Avoid wearing gloves in front of the child and family.

ANS: C

Standard Precautions should always be used when handling body fluids. Specimen collection is not always a sterile procedure. Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so that they will not be offended or frightened.

PTS: 1 DIF: Cognitive Level: Application REF: 1151

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

33. Which information should the nurse include in teaching parents how to care for a childs gastrostomy tube at home?

a.

Never turn the gastrostomy button.

b.

Clean around the insertion site daily with soap and water.

c.

Expect some leakage around the button.

d.

Remove the tube for cleaning once a week.

ANS: B

The skin around the tube insertion site should be cleaned with soap and water once or twice daily. The gastrostomy button should be rotated in a full circle during cleaning. Leakage around the tube should be reported to the physician. A gastrostomy tube is placed surgically. It is not removed for cleaning.

PTS: 1 DIF: Cognitive Level: Application REF: 1186

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

34. Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy?

a.

Set the oxygen flow rate at less than 6 L/min.

b.

Make sure the mask fits properly.

c.

Keep the child warm.

d.

Remove the mask for 5 minutes every hour.

ANS: B

A properly fitting face mask is essential for adequate oxygen delivery. The oxygen flow rate should be greater than 6 L/min to prevent rebreathing of exhaled carbon dioxide. Oxygen delivery through a face mask does not affect body temperature. A face mask used for oxygen therapy is not routinely removed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1177

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

35. What is critical information for the nurse to incorporate into her care when using restraints on a child?

a.

Use the least restrictive type of restraint.

b.

Tie knots securely so they cannot be untied easily.

c.

Secure the ties to the mattress or side rails.

d.

Remove restraints every 4 hours to assess skin.

ANS: A

When restraints are necessary, the nurse should institute the least restrictive type of restraint. Knots must be tied so that they can be easily undone for quick access to the child. The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.

PTS: 1 DIF: Cognitive Level: Application REF: 1148

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

36. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action?

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, favorite foods should be requested for the child. These foods provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

PTS: 1 DIF: Cognitive Level: Application REF: 1192

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

37. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics:

a.

May cause malignant hyperthermia.

b.

May cause febrile seizures.

c.

Are of no value in treating hyperthermia.

d.

Are of limited value in treating hyperthermia.

ANS: C

Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics do not cause seizures and are of no value in hyperthermia.

PTS: 1 DIF: Cognitive Level: Application REF: 1144

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

38. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurses best action is to:

a.

Prepare child for conscious sedation during the test.

b.

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

c.

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

d.

Apply EMLA to puncture site 15 minutes before procedure.

ANS: A

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. Reassuring the parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of local anesthetics) should be applied approximately 60 minutes before the procedure. The emergency nature of the spinal tap precludes its use.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1150

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

39. The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which procedure is recommended to facilitate this?

a.

Apply cool, moist compresses.

c.

Elevate the foot for 5 minutes.

b.

Apply a tourniquet to the ankle.

d.

Wrap foot in a warm washcloth.

ANS: D

Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1155

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

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

a.

Keep arm extended while applying a bandage to the site.

b.

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

c.

Apply a bandage 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 is applied.

PTS: 1 DIF: Cognitive Level: Application REF: 1154

OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

41. Which is the preferred site for intramuscular injections in infants?

a.

Deltoid

c.

Rectus femoris

b.

Dorsogluteal

d.

Vastus lateralis

ANS: D

The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1160

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

42. Nursing considerations related to the administration of oxygen in an infant include to:

a.

Humidify the oxygen if the infant can tolerate it.

b.

Assess the infant to determine how much oxygen should be given.

c.

Ensure uninterrupted delivery of the appropriate oxygen concentration.

d.

Direct the oxygen flow so that it blows directly into the infants face in a hood.

ANS: C

Oxygen is a prescribed medication. It is the nurses responsibility to ensure that the ordered concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the tissues. Oxygen should always be humidified when delivered to a patient. A child receiving oxygen therapy should have the oxygen saturation monitored at least as frequently as vital signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage as indicated. Humidified oxygen should not be blown directly into an infants face.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 1177

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

43. When administering a gavage feeding to a school-age child, the nurse should:

a.

Lubricate the tip of the feeding tube with Vaseline to facilitate passage.

b.

Check the placement of the tube by inserting 20 mL of sterile water.

c.

Administer feedings over 5 to 10 minutes.

d.

Position the child on the right side after administering the feeding.

ANS: D

Position the child with the head elevated about 30 degrees and on the right side or abdomen for at least 1 hour. This is in the same manner as after any infant feeding to minimize the possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube, while simultaneously listening with a stethoscope over the stomach area. Feedings should be administered via gravity flow and take from 15 to 30 minutes to complete.

PTS: 1 DIF: Cognitive Level: Application REF: 1184

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

44. The nurse is doing a prehospitalization orientation for a 7-year-old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is:

a.

Unnecessary.

b.

The surgeons responsibility.

c.

Too stressful for a young child.

d.

An appropriate part of the childs preparation.

ANS: D

Explanation is a necessary part of preoperative preparation. If the child wakes and is not prepared for the inability to speak, she will be even more anxious. This is a necessary component for preparation for surgery that will help reduce the anxiety associated with surgery. It is a joint responsibility of nursing, medical staff, and child life personnel.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1132

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

MULTIPLE RESPONSE

45. The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required (Select all that apply)?

a.

Catheterized urine collection

b.

Intravenous (IV) line insertion

c.

Oxygen administration

d.

Lumbar puncture

e.

Computed tomography (CT) scan with contrast

ANS: D, E

Informed consent is required for invasive procedures that involve risk to a child, such as a lumbar puncture, chest tube insertion, and bone marrow aspirations. A consent is also required for a CT scan with contrast. Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian. Catheterized urine collection, IV line insertion, and oxygen administration all fall under this category.

PTS: 1 DIF: Cognitive Level: Application REF: 1130

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

46. The advantages of the ventrogluteal muscle as an injection site in young children include which of the following (Select all that apply)?

a.

Less painful than vastus lateralis

b.

Free of important nerves and vascular structures

c.

Cannot be used when child reaches a weight of 20 pounds

d.

Increased subcutaneous fat, which increases drug absorption

e.

Easily identified by major landmarks

ANS: A, B, E

Less painful, free of important nerves and vascular structures, and easily identifiable are advantages of the ventrogluteal muscle. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. Cannot be used when a child is 20 pounds or more and increased subcutaneous fat are not advantages of the ventrogluteal muscle as an injection site in young children.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1160

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

47. A nurse is caring for a child in Droplet Precautions. Which instructions should the nurse give to the unlicensed assistive personnel caring for this child (Select all that apply)?

a.

Wear gloves when entering the room.

b.

Wear an isolation gown when entering the room.

c.

Place the child in a special air handling and ventilation room.

d.

A mask should be worn only when holding the child.

e.

Wash your hands upon exiting the room.

ANS: A, B, E

Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves, gowns, and a mask should be worn when entering the room. Hand washing when exiting the room should be done with any patient. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission.

PTS: 1 DIF: Cognitive Level: Application REF: 1146

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

COMPLETION

48. A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the childs weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be _____ milligrams. Record your answer using one decimal place.

ANS:

0.5

Calculate the dosage by weight: 0.07 mg/day 7.2 kg = 0.5 mg/day.

PTS: 1 DIF: Cognitive Level: Analysis REF: 1171

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MATCHING

The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent suctioning after abdominal surgery. Place in correct sequence the steps for inserting a nasogastric tube.

a.

Lubricate the nasogastric tube with water-soluble lubricant.

b.

Tape the nasogastric tube securely to the childs face.

c.

Check the placement of the tube by aspirating stomach contents.

d.

Place the child in the supine position with head slightly hyperflexed.

e.

Insert the nasogastric tube through the nares.

f.

Measure the tube from the tip of the nose to the earlobe to the midpoint between the xiphoid process and the umbilicus.

49. Step one

50. Step two

51. Step three

52. Step four

53. Step five

54. Step six

49. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

50. ANS: F PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

51. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

52. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

53. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

54. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 1187 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

NOT: Once the tube has been successfully inserted, it should be checked for correct placement.

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