Pediatric Nursing Exam Questions and Answers, Exams of Nursing

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An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action? A. Ask the laboratory to perform virologic testing Correct B. Obtain blood from the umbilical cord to send to the laboratory C. Perform a heelstick to obtain a specimen for a Western blot assay D. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent assay (ELISA) accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results. Test-Taking Strategy: Focus on the subject , newborn infant exposed to HIV. Recalling that the ELISA and Western blot assay are not accurate in an infant younger than 18 months will assist you in eliminating these options. Next eliminate the option involving cord blood, knowing that such blood could be contaminated. Review: tests for HIV in newborn Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Infectious Diseases Giddens Concepts: Immunity, Infection HESI Concepts: Immunity, Infection Awarded 98.0 points out of 98.0 possible points.

A nurse providing home care instructions to a mother of a HIV-positive child discusses measures to prevent transmission of the virus. Which statement by the mother indicates a need for further instruction? A. “I won’t let my children share toothbrushes.” B. “I’ll wash up blood spills with soap and hot water and allow them to air dry.” Correct C. “I’ll wash my hands with soap and water if I touch any blood from my child.” D. “I’ll rinse bloodstained clothing with hydrogen peroxide and then wash it as usual.” Rationale: The correct method of cleaning up blood spills is to wash the area with soap and water, rinse with bleach, and let the area air dry. The remaining statements by the mother reflect correct measures to prevent transmission of the virus. Test-Taking Strategy: Focus on the subject , transmission of HIV virus. Note the strategic words “ need for further instruction ,” which indicates a negative event query and the need to select the incorrect statement. Recalling that blood spills must be cleaned with a 1: Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not

bleach/water solution will direct you to the correct option. Review: home care measures for HIV Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Diseases Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A child has been in the hospital for several days for treatment of severe vomiting related to his HIV-positive status. Which assessment finding is the best indication that the child’s condition is improving? A. No lesions in the mouth and throat B. Weight increase of 1 lb (0.45 kg) over 3 days Correct C. Temperature change from 100.2° F to 99.2° F (37.3°C) D. Capillary refill slowing from 2 seconds to 3 seconds Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating fluid volume increase (the desired outcome) is weight. A temperature decrease is not reflective of fluid volume increase. Increasing capillary refill time is indicative of a fluid volume decrease, not an increase. The absence of mouth ulcers would allow the child to drink without pain but does not reflect a fluid volume increase. Test-Taking Strategy: Note the data in the question and the strategic word best , and remember that the child is experiencing severe vomiting. Use the process of elimination and focus on the subject , an assessment finding indicating fluid volume increase. The correct option is the only one related to fluid volume. Review: child with HIV and severe vomiting Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Infectious Diseases Giddens Concepts: Fluid and Electrolytes, Evidence HESI Concepts: Evidence-Based Practice/Evidence, Fluids and Electrolytes Awarded 98.0 points out of 98.0 possible points.

A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide which information to the girl? A. She cannot be exposed to any sunlight at all B. She must bring a beach umbrella and remain under it all day C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity Correct

D. It is all right to go to the beach as long as she wears sunglasses, a sun hat, and clothes that cover her entire body Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of the connective tissue, varies in severity and is marked by remissions and exacerbations. Although the origin of SLE is not known, genetic, environmental, hormonal, and immune response factors are likely responsible. These factors include exposure to sun and other UV light, stress, fatigue, viruses, bacteria, certain medications, and some food additives. Avoiding triggers that set off exacerbation is essential, so wearing appropriate sunscreen is a necessity. The sunscreen should contain an SPF higher than 15 and should be waterproof. The remaining options present incorrect information. Test-Taking Strategy: Focus on the subject , girl with SLE. Eliminate the options that are comparable or alike in that they indicate that exposure to sunlight must be avoided. Also, noting the close-ended words “cannot” and “must” will help you eliminate these options. Review: preventing exacerbation of SLE Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Safety Giddens Concepts: Client Education, Immunity HESI Concepts: Immunmity, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes that the child’s urine output has been 1 mL/kg/hr over the past 3 hours and that the specific gravity of the urine is 1.020. Which is the appropriate nursing action? A. Contact the pediatrician B. Document the findings Correct C. Encourage the child to drink more fluids D. Increase the rate of flow of the intravenous (IV) solution Rationale: The appropriate nursing action is for the nurse to document the findings, because they are normal. Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2 mL/kg/hr in preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age children or adolescents indicates dehydration. A specific gravity of the urine above 1.020 may indicate dehydration. Test-Taking Strategy: Focus on the subject , child with dehydration. Note the data in the question , and the strategic word “ appropriate”. This indicates the best action by the nurse. Eliminate the options that indicate the need to implement additional treatment. Additionally, note that these options indicate increasing fluid intake. Remember also that the nurse would not increase the rate of IV fluids without a pediatrician’s prescription to do so. Review: urine output and specific gravity in school-age child Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation

Awarded 98.0 points out of 98.0 possible points.

Intravenous potassium chloride (KCL) in 0.9% sodium chloride solution has been prescribed for a child who is severely dehydrated. Before administering the solution, the nurse must take which priority action? A. Check urine output Correct B. Evaluate skin turgor C. Measure capillary refill D. Obtain the child’s blood pressure Rationale: The nurse’s priority action is to check the child’s urine output. Potassium chloride is not administered if the urine output is not adequate. If the child is anuric, potassium will be retained, causing an increased potassium level. Although skin turgor, capillary refill, and blood pressure may be checked, they are not essential assessments in this situation. Test-Taking Strategy: Focus on the subject , severely dehydrated child to receive intravenous solution of KCL. Note the strategic word “ priority .” Eliminate the options that refer to clinical signs/symptoms of dehydration — skin turgor and capillary refill. Focus on what the question is asking about the administration of a particular solution. Review: IV potassium chloride Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Intravenous Therapy Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is monitoring a 3-year-old with diarrhea for signs/symptoms of dehydration. The child now weighs 42 lb (19 kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition to dry mucous membranes and lack of tears, what assessment finding would the nurse find? A. Decreased heart rate B. Bilateral 1+ pedal pulses Correct C. Increased blood pressure D. Urine output of 80 mL in the last 3 hours Rationale: The assessment finding the nurse would expect to find in the child with dehydration is a bilateral 1+ pedal pulse that is difficult to palpate, weak, and thready. The minimum urine output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80 mL in the last 4 hours is within the minimum range. A child with dehydration will have a rapid, weak, thready pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign of hypovolemia. Test-Taking Strategy: Focus on the subject , signs/symptoms of dehydration. Thinking about HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes Content Area: Fluids and Electrolytes

the pathophysiology of dehydration will direct you to the correct option. Review: child with dehydration Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluids & Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluid and Electrolytes Awarded 98.0 points out of 98.0 possible points.

A nurse is assigned to care for a child with diarrhea. Which intervention should the nurse avoid in caring for the child? A. Wearing clean gloves B. Turning the child every 2 hours C. Using protective moisture barriers D. Taking a rectal temperature every 4 hours Correct thermometer in the rectum stimulates peristalsis and may damage excoriated tissue. Gloves are worn when caring for the child. Clean gloves are sufficient; sterile gloves are not necessary in this situation. The child is turned every 2 hours to reduce pressure on irritated skin and to prevent skin breakdown. Protective moisture barriers, such as creams or ointments, are useful in protecting the skin from diarrhea stools. Test-Taking Strategy: Note the strategic word “ avoid ,” which indicates a negative event query and the need to select the incorrect intervention. Focusing on the child’s diagnosis and recalling that peristalsis would aggravate the condition will direct you to the correct option. Review: child with diarrhea Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points.

A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply. A. “I should put her on her stomach to sleep.” B. “I shouldn’t brush her teeth for 1 to 2 weeks.” Correct C. “I should rinse her mouth with water after feeding her.” Correct D. “I should watch for signs/symptoms of infection like drainage or fever.” Correct E. “I should never use a bulb syringe to clear secretions from her mouth.” Rationale: Rectal temperatures are avoided in the child with diarrhea because inserting a

Rationale: “I shouldn’t brush her teeth for 1 to 2 weeks,” “I should rinse her mouth with water after feeding her,” and “I should watch for signs/symptoms of infection like drainage or fever” are all accurate statements. Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb syringes are often sent home with the family for removal of these secretions. After cleft lip repair the child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position could result in contact of the suture line with the bed linens, leading to disruption of the suture line. Test-Taking Strategy: Focus on the subject , an understanding of home care measures. Consider the safety issues related to oral surgery and positioning and wound care. Visualize each of the options to answer correctly. Review: cleft lip repair Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A newborn is found to have esophageal atresia (EA) with tracheoesophageal fistula (TEF). In which position does the nurse immediately place the infant? A. Trendelenburg B. Flat and side-lying C. Prone, with the head of the bed flat D. Supine, with the head of the bed elevated Correct Rationale: EA and TEF are congenital malformations in which the esophagus terminates before it reaches the stomach, a fistula forms an unnatural connection with the trachea, or both. Keeping the infant supine, with the head of the bed elevated, decreases the likelihood that gastric secretions will enter the lungs. Placing the child in the Trendelenburg position, flat and side-lying, or prone with the head of the bed flat is incorrect; any of these positions could result in the aspiration of gastric secretions. Test-Taking Strategy: Focus on the subject , infant with EA and TEF. Note the strategic word , “ immediately ” and recall the pathophysiology of this disorder. Recalling that the primary concern is aspiration of gastric secretions will direct you to the correct option. Review: infant with EA and TEF Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is assigned to care for an infant with congenital diaphragmatic hernia (CDH). Which clinical finding supports this diagnosis? A. Presence of an anal membrane B. Failure to pass meconium stool C. Viscera located outside the abdominal cavity D. Auscultation of cardiac sounds on the right side of the chest Correct Rationale: CDH is an opening in the diaphragm through which abdominal contents herniate into the thoracic cavity during prenatal development. Clinical findings depend on the severity of the defect but may include the presence of abdominal organs in the chest (revealed by fetal ultrasonography), diminished breath sounds or an absence of such sounds on the affected side, auscultation of bowel sounds over the chest, auscultation of cardiac sounds on the right side of the chest, respiratory distress, and a scaphoid abdomen. The presence of an anal membrane and failure to pass meconium stool are findings noted in imperforate anus. The presence of viscera outside the abdominal cavity is noted in gastroschisis. Test-Taking Strategy: Focus on the subject , child with CDH. Eliminate first the options that are comparable or alike in that they are related to an imperforate anus. To select from the remaining options, focus on the name of the disorder and use your knowledge of the pathophysiology of CDH to find the correct option. Review: CDH Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points.

A nurse provides home care instructions to the mother of an infant with gastroesophageal reflux disease (GERD). Which statement by the mother indicates a need for further instruction? A. “I shouldn’t give the baby a pacifier.” Correct B. “I should thicken feedings with rice cereal.” C. “I should put the baby on her right side with her head raised.” D. “I need to give the baby small, frequent feedings and use a predigested formula.” Rationale: The use of a pacifier allows the infant to practice swallowing. Pacifier use also decreases the incidence of crying and reflux episodes and may increase clearance of reflux stomach contents. Small, frequent feedings of a predigested formula will reduce the amount of formula in the stomach, ease distension, and minimize reflux. These smaller, more frequent feedings with frequent burping are often tried as the first line of treatment. Thickened feedings tend to decrease the chances of reflux, vomiting, and aspiration. Placing the affected infant in a 30 - degree head-elevated prone or right-side–lying position helps prevent reflux. Test-Taking Strategy: Focus on the subject , infant with GERD. Note the strategic words “ need for further instruction .” These words indicate a negative event query and the

need to select the incorrect statement. Think about the pathophysiology associated with this disorder to assist in directing you to the correct option. Review: home care for infant with GERD Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A nurse, providing information to the mother of a child with irritable bowel syndrome (IBS) should tell the mother what about the syndrome? A. There is no cure B. Fiber must be eliminated from the diet C. Treatment is aimed at relieving the signs/symptoms Correct D. Surgery and creation of a permanent colostomy will be necessary Rationale: There is no definitive treatment for irritable bowel syndrome. Instead, treatment is aimed at relieving the signs/symptoms. The primary nursing intervention is reassurance that irritable bowel syndrome is a self-limiting, intermittent problem. Unless lactose intolerance is suspected, a healthy, well-balanced, moderate-fiber diet should be followed. The child is encouraged to eat slowly. Surgery and creation of a permanent colostomy are not necessary. Test-Taking Strategy: Focus on the subject , child with IBS. Use your knowledge regarding treatment for this syndrome. Eliminate the options containing the closed-ended words “ no ,” “ must ,” and “ permanent .” Review: irritable bowel syndrome (IBS) Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Elimination HESI Concepts: Elimination, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A nurse is preparing a child admitted from the emergency department with a diagnosis of acute appendicitis for an appendectomy, to be performed in an hour. The child tells the nurse that the acute abdominal pain has suddenly subsided. The priority nursing intervention is which? A. Contact the surgeon Correct B. Document the findings C. Tell the parents that the pain was probably a result of gastroenteritis D. Inform the operating room that the surgery will probably be canceled Rationale: If a ruptured appendix is suspected, the nurse’s priority action is to immediately contact the surgeon. In appendicitis, sudden relief of pain may indicate that the appendix has

ruptured. The temporary relief from pain is followed by an increase in pain, a rigid abdomen, and early shock symptoms. The nurse would document the findings but would contact the surgeon first, because a ruptured appendix is an emergency. The surgery will not be canceled. This manifestation is not a result of gastroenteritis. Test-Taking Strategy: Focus on the subject , child with acute appendicitis. Note the strategic word “ priority ,”. This indicates the nurse’s first and most important action. Next, focus on the data in the question. Recalling that rupture is a concern in a child with acute appendicitis and recalling the manifestations of appendiceal rupture will direct you to the correct option. Review: complications of acute appendicitis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse has provided dietary instructions to the mother of a child with Crohn’s disease. Which statements by the mother indicate an understanding of the instructions? Select all that apply. A. “It’s important to include meat in his diet.” B. “I won’t give him/her high-fiber vegetables like corn.” Correct C. “Snacks such as nuts will help provide the extra protein he/she needs.” Correct D. “I should give him/her ice cream every day to be sure that he gets his calcium.” E. I’ll make sure that he/she takes a multivitamin and iron supplement every day.” Correct Rationale: A well-balanced, high-protein, high-calorie diet is recommended in Crohn’s disease; a multivitamin and iron supplement should also be taken. Meat is high in protein and necessary for optimal growth and development. High-fiber foods such as corn, nuts, and seeds can produce obstructions in children with intestinal strictures and should be avoided. Ice cream is a milk product and should be avoided. Test-Taking Strategy: Focus on the subject , a child with Crohn’s disease. Recalling that Crohn’s disease is an inflammatory bowel disease will direct you to the correct options. Review: dietary measures for Crohn’s disease Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Elimination HESI Concepts: Elimination, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

What manifestation of hypertrophic pyloric stenosis should the nurse reviewing the record of an infant with this disorder expect to see documented?

A. Fever B. Profuse diarrhea C. Alternating constipation and diarrhea and fecal impaction D. Olive-shaped mass palpated in the right upper abdominal quadrant Correct Rationale: The nurse would expect to see documented a movable, palpable, firm, olive-shaped mass felt in the right upper quadrant. This mass is most easily palpated when the stomach is empty and the infant is relaxed. Progressive non-bilious projectile vomiting in a previously healthy infant is a major sign/synptom of pyloric stenosis. The vomitus may become blood- tinged if esophageal irritation occurs. Deep gastric peristaltic waves from the left upper quadrant to the right upper quadrant may be visible immediately before vomiting commences. If the condition progresses, the infant may become dehydrated and experience metabolic alkalosis. Fever, profuse diarrhea, and alternating constipation and diarrhea and fecal impaction are not manifestations of this disorder. Test-Taking Strategy: Focus on the subject , manifestations of hypertrophic pyloric stenosis. First, eliminate the options that involve diarrhea. To select from the remaining options, note that the diagnosis involves the gastrointestinal system; this will direct you to the correct option. Review: hypertrophic pyloric stenosis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points.

A nurse is caring for an infant scheduled for a pyloromyotomy. In which position should the nurse place the infant for the preoperative period? A. Prone B. Supine C. Head elevated Correct D. Trendelenburg Rationale: In the preoperative period, the infant’s head of the bed is elevated to reduce the risk of aspiration. The nurse would use blankets or towel rolls to maintain this position. Prone, supine, and Trendelenburg are incorrect positions because they increase the risk of aspiration. Test-Taking Strategy: First eliminate the options that are comparable or alike in that the head of the bed is flat. Next, recall that aspiration is a concern; this will direct you to the correct option. Review: pyloromyotomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal

Awarded 98.0 points out of 98.0 possible points.

Hydrostatic reduction is performed in a hospitalized child with a diagnosis of intussusception. Which outcome indicates that the procedure was successful? A. Passage of barium in the stool B. Passage of stool without blood Correct C. Visible peristalsis across the abdomen D. Presence of a sausage-shaped abdominal mass Rationale: The passage of stool without blood is a successful outcome for a child who has had a hydrostateic reduction. Intussusception is an invagination of a section of the intestines into the distal bowel that results in bowel obstruction. In children, this condition most often occurs as a section of the terminal ileum telescopes into the ascending colon through the ileocecal valve. The goal of treatment is to restore the bowel to its normal position and function as quickly as possible. In children who do not show symptoms of shock or sepsis, attempts at hydrostatic reduction are made with the use of a barium or air enema until a free flow of barium into the terminal ileum is evident. The nurse watches for the passage of barium after this procedure, but it does not indicate a successful procedure. Visible peristalsis across the abdomen is a manifestation of Hirschprung’s disease. Presence of a sausage-shaped abdominal mass is a sign of intussusception. Test-Taking Strategy: Focus on the subject , “a successful outcome.” Recalling the signs/symptoms of intussusception and the purpose of hydrostatic reduction will direct you to the correct option. Review: hydrostatic reduction Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Gastrointestinal Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points.

A nurse is providing information to the parents of a child with suspected Hirschsprung’s disease. The nurse informs the parents that diagnosis is definitively confirmed by the findings of which action? A. Blood tests B. Rectal biopsy Correct C. Barium enema D. Rectal examination Preoperative interventions HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Giddens Concepts: Clinical Judgment, Safety

Hirschsprung’s disease. Blood tests are not used to diagnose the disease. A barium enema and a rectal examination will detect significant characteristics of the disease but will not confirm the diagnosis. Test-Taking Strategy: Focus on the subject , confirming the diagnosis. Recalling the pathophysiology of this disease and remembering that a biopsy will identify the characteristics of tissues will direct you to the correct option. Review: Hirschsprung’s disease Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Gastrointestinal Giddens Concepts: Elimination, Evidence HESI Concepts: Elimination, Evidence-Based Practice/Evidence Awarded 98.0 points out of 98.0 possible points.

A nurse is caring for an infant with Hirschsprung’s disease. Which manifestation of the disease should the nurse expect to note? A. Non-bilious projectile vomiting B. Foul-smelling, ribbon-like stools Correct C. A sausage-shaped abdominal mass D. Bloody, mucousy “currant jelly” stools Rationale: The child with Hirschsprung’s disease will have constipation that has been present since the neonatal period and the frequent passage of foul-smelling, ribbon-like or pellet stools. Non-bilious projectile vomiting is a manifestation of pyloric stenosis. Bloody, mucousy “currant jelly” stools and a sausage-shaped abdominal mass are manifestations of intussusception. Test-Taking Strategy: Focus on the subject , the manifestations of Hirschsprung’s disease. Recalling that Hirschsprung’s disease is characterized by the absence of ganglionic cells will direct you to the correct option. Review: manifestations of Hirschsprung’s disease Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Gastrointestinal Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 1074). St Louis: Mosby. Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points.

mucosa is removed. Absence of ganglionic cells in the sample confirms the diagnosis of biopsy. During biopsy, a small core or punch sample that contains all layers of the bowel Rationale: The definitive diagnosis of Hirschsprung’s disease is made by means of rectal

Which high-calcium food does the nurse direct the parents of a child with lactose intolerance to include in the child’s diet? A. Yogurt B. Raisins C. Broccoli Correct D. Ice cream intolerance should avoid all high-lactose foods, such as milk, yogurt, and ice cream. Foods that are high in calcium and will be tolerated by a child with lactose intolerance include egg yolk, dried beans, cauliflower, and molasses. Raisins are high in magnesium and phosphorus. Test-Taking Strategy: Noting the subject , foods high in calcium, will assist you in eliminating raisins. To select from the remaining options, focus on the child’s diagnosis and recall that yogurt and ice cream are high in lactose; this will direct you to the correct option. Review: lactose intolerance Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Nutrition HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition Awarded 98.0 points out of 98.0 possible points.

A nurse is providing information to the mother of a child with newly diagnosed celiac disease. What piece of information should the nurse include? A. An infection can precipitate a celiac crisis. Correct B. The disease can be cured with medication. C. Pasta is an appropriate part of the child’s diet. D. Temporary dietary modifications may be necessary to heal the gastrointestinal tract. Rationale: Dietary management is the mainstay of treatment for celiac disease. This disease is the result of an inability to digest fully the gliadin, or protein, part of wheat, barley, rye, and oats. This lifelong deficiency requires dietary modifications to prevent chronic maldigestion and malabsorption. All wheat, barley, rye, and oats (i.e., pasta, baked products, and many breakfast cereals) should be eliminated from the diet and replaced with corn and rice. Celiac crisis is marked by profuse, watery diarrhea and vomiting and can quickly lead to severe dehydration and metabolic acidosis. Test-Taking Strategy: Focus on the subject , the characteristics of celiac disease. Knowing that the disease cannot be cured and remembering that lifelong dietary management, which includes the elimination of wheat, barley, rye, and oats, is the primary treatment will direct you to the correct option. Review: celiac disease and celiac crisis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Rationale: Yogurt, ice cream, and broccoli are high in calcium, but the child with lactose

Integrated Process: Teaching and Learning Content Area: Child Health—Gastrointestinal Giddens Concepts: Client Education, Elimination HESI Concepts: Elimination, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A nurse is providing information to parents about the transmission of hepatitis. The nurse should tell the parents that hepatitis A virus (HAV) is primarily transmitted in which way? A. During birth B. By way of sexual contact C. In blood and blood products D. In contaminated food or water Correct Rationale: HAV is transmitted by way of the fecal-oral route and in food or water contaminated with HAV. Hepatitis B virus is transmitted by way of blood, blood products, and secretions; prenatally or perinatally; during sexual contact; and in breast milk. Hepatitis C virus is transmitted perinatally or through blood and blood products. Test-Taking Strategy: Focus on the subject , transmission of HAV. Note the strategic word , “ primarily ”. Remember that HAV is transmitted by way of the fecal-oral route and in HAV- contaminated food or water. Review: hepatitis A Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Child Health—Infectious Diseases Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

The nurse is discharging a child with primary nocturnal enuresis. Which statements by the parents indicate that they understand the techniques used to manage this disorder? Select all that apply. A. “An alarm system might help prevent the bedwetting.” Correct B. “We need to limit his fluid intake throughout the day.” C. “We need to be sure that he urinates just before bedtime.” Correct D. “We’ve already developed a reward system for when he stays dry for a certain number of consecutive nights.” Correct E. “We’ll teach him to perform Kegel or pelvic muscle exercises and encourage him to do them every hour of the day.” Rationale: Treatment of primary nocturnal enuresis includes limiting fluids after supper (not throughout the day) and encouraging the child to urinate before bedtime. A reward system of some type may be helpful, and the child and parents can decide on a special reward when the child has achieved a certain number of consecutive dry nights. Behavioral conditioning with the use of alarms may be helpful. One such alarm system includes a device worn on the child’s

pajamas that contains a moisture-sensitive alarm. As the child starts to void, the alarm goes off, awakening the child. Kegel or pelvic muscle exercises may be helpful for daytime enuresis but are not useful in preventing nocturnal enuresis. Test-Taking Strategy: Focus on the subject , managing primary nocturnal enuresis. Read each option carefully. Remembering that fluid intake is not normally limited in children because dehydration is likely to develop and understanding that performing Kegel or pelvic muscle exercises 24 hours a day will disrupt sleep will assist you in answering correctly. Review: primary nocturnal enuresis Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health—Renal Giddens Concepts: Client Education, Elimination HESI Concepts: Elimination, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

What instruction should the nurse provide to a parent regarding the prevention of urinary tract infection in his child? A. Wrap the diaper tightly on the child B. Avoid giving the child bubble baths Correct C. Use underwear made of a synthetic fabric D. Encourage the child to hold the urine to avoid frequent voiding Rationale: Bubble baths should be avoided because they may irritate the urinary tract and lead to urinary tract infections. Tight clothing or diapers are avoided, and cotton underwear, rather than a synthetic fabric, should be used to prevent irritation that could lead to infection. The child should be encouraged to avoid holding urine and to urinate at least four times per day, emptying the bladder completely. Test-Taking Strategy: Focusing on the subject , preventing a urinary tract infection, and recalling the causes of a urinary tract infection will direct you to the correct option. Review: urinary tract infections Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Renal Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A nurse is caring for an infant with hypospadias. What does the nurse make a priority when assessing the infant? A. Blood pressure B. Urinary output Correct C. Level of consciousness

D. Gastrointestinal function priority of assessing urinary function in the infant. Blood pressure, level of consciousness, and gastrointestinal function are unrelated to this disorder. Test-Taking Strategy: Focus on the subject , infant with hypospadias. Note the strategic word , “ priority ”. This indicates the first and most important assessment by the nurse. Recalling the pathophysiology of hypospadias will direct you to the correct option. Review: hypospadias Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Elimination HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination Awarded 98.0 points out of 98.0 possible points.

A nurse is performing an assessment of a school-age child admitted with acute poststreptococcal glomerulonephritis. Which question would help determine the cause of this acute condition? A. “Have you fallen off your bicycle recently?” B. “Did you have a sore throat a few weeks ago?” Correct C. “Have you had chickenpox in the last 2 months?” D. “Have you eaten any shrimp or crab in the last 7 to 10 days?” Rationale: Acute poststreptococcal glomerulonephritis occurs as an immune reaction to a group A beta-hemolytic streptococcal infection of the throat or skin. Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Acute poststreptococcal glomerulonephritis, the most common type, is characterized by hematuria, proteinuria, edema, and renal insufficiency. Falling off a bicycle, contracting chickenpox, and eating shellfish are not causes of acute glomerulonephritis. Test-Taking Strategy: Focus on the subject , the origin of this disorder. Note the relationship between the word “poststreptococcal” in the client’s diagnosis and the correct option. Review: glomerulonephritis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Awarded 98.0 points out of 98.0 possible points.

Which laboratory result would the nurse expect to see in a child admitted to the hospital with acute glomerulonephritis? meatus is below the normal placement on the glans of the penis. The nurse would make a Rationale: Hypospadias is a congenital anomaly in which the actual opening of the urethral

A. Hematocrit of 38% B. 2+ protein in the urine Correct C. Serum potassium of 3.8 mEq/L (3.8 mmol/L)mg/dL D. White blood cell (WBC) count of 9800 cells/mm^3 (9.8 x 10 9/L) microscopic hematuria with red cast cells, which indicate glomerular injury. Proteinuria is also present. Blood chemistry values are usually within the normal ranges. If renal insufficiency is severe, however, the blood urea nitrogen and creatinine levels are increased. The complete blood count usually demonstrates normal a WBC count and mild anemia. The lower hemoglobin and hematocrit values reflect the dilutional effect of extra fluid in the blood, a result of decreased glomerular filtration. Electrolyte disturbances such as a high serum potassium level and low serum bicarbonate level may result from inadequate glomerular filtration. All laboratory values identified in the options are normal, with the exception of the urinary protein level. Test-Taking Strategy: Focus on the subject , laboratory findings in acute glomerulonephritis. Recalling the pathophysiology of acute glomerulonephritis and recalling normal laboratory findings will direct you to the correct option. Review: laboratory findings of acute glomerulonephritis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Cellular Regulation, Infection HESI Concepts: Cellular Regulation, Infection Awarded 98.0 points out of 98.0 possible points.

A nurse is performing an assessment of a child with nephrotic syndrome. Which manifestation would the nurse most likely note? A. Periorbital edema Correct B. Weight loss of 1.5 kg C. Temperature of 99.2° F (37.3°C) D. Blood pressure of 128/86 mm Hg Rationale: The manifestation the nurse would most likely note is edema (primarily noted in the periorbital spaces and dependent areas of the body). Other signs/symptoms include anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. Nephrotic syndrome is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. The child with nephrotic syndrome usually has a normal blood pressure. Fever may occur if an infection is present. Test-Taking Strategy: Focus on the subject , nephrotic syndrome. Note the strategic words “ most likely .” Recalling that nephrotic syndrome is a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema will direct you to the correct option. Review: nephrotic syndrome diagnosis of acute poststreptococcal glomerulonephritis. Urinalysis reveals macroscopic or Rationale: History, presenting signs/symptoms, and laboratory results can establish the

Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Renal Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes Infection Awarded 98.0 points out of 98.0 possible points.

Which medication is essential for the nurse to have available before administering an allergy injection to a child? A. Ibuprofen B. Epinephrine Correct C. Acetaminophen D. Immune globulin Rationale: Emergency epinephrine is essential for the nurse to have available when allergy injections are being administered to treat a hypersensitivity reaction, if one occurs. Immune globulin is an immune serum used to provide passive immunity or prevent acute infection in immunocompromised clients. Ibuprofen is a nonsteroidal antiinflammatory medication, and acetaminophen is an analgesic; neither is an appropriate treatment for a hypersensitivity reaction. Test-Taking Strategy: Focus on the subject , allergy injection for a child. Note the strategic word , “ essential ”. Use your knowledge of the actions of the medications listed in the options. Recalling that a hypersensitivity reaction may occur when allergy injections are administered and recalling the classification and uses of each medication in the options will direct you to the correct option. Review: medications for allergic reaction Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Immunity, Safety HESI Concepts: Immunity, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is providing home care instructions to the mother of a child with sinusitis. Which statement by the mother indicates a need for further instruction? A. “Acetaminophen can help relieve the discomfort.” B. “I need to encourage him to drink clear liquids.” C. “Breathing cool, moist air will help drain his sinuses.” Correct D. “I can put warm, moist compresses over his sinuses to make him feel better.” Rationale: Breathing warm (not cool) mist in a shower can help liquefy and mobilize nasal mucus. Acetaminophen is given to reduce fever and alleviate discomfort. Sinus drainage is

facilitated by increasing the child’s intake of clear fluids. Warm, moist compresses applied two or three times a day help ease swelling and pain. Test-Taking Strategy: Note the strategic words “ need for further instruction ,” which indicate a negative event query and the need to select the incorrect statement. Recalling the effects of warm and cool treatments will direct you to the correct option. Review: child with sinusitis Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health – Throat and Respiratory Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

Which pediatric client is at least risk for otitis media? A. A breastfed infant Correct B. A bottle-fed infant C. A child who attends a daycare center D. A child exposed to environmental smoke Rationale: The pediatric client who is at least risk for otitis media is the breaastfed infant. Breastfeeding offers some protection against ear infection by providing maternal antibodies and by decreasing the incidence of allergy. Also, the more upright the position of the infant during nursing, the greater the protection against ear infection. Bottle feeding contributes to ear infection because of the position of the infant during feeding. Also, reflux of formula into the eustachian tube from the nasopharynx may occur when the infant swallows while in a supine position. Attendance at a daycare center predisposes a child to otitis media. Exposure to environmental smoke is a risk factor. Test-Taking Strategy: Focus on the subject , otitis media. Note the strategic words “ least risk .” Recalling that breast milk provides maternal antibodies will direct you to the correct option. Review: otitis media Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Child Health—Ear Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Awarded 98.0 points out of 98.0 possible points.

A nurse provides home care instructions to the mother of a child who has undergone myringotomy with the insertion of tympanostomy tubes. Which statement by the mother indicates a need for further instruction? A. “A fever is normal after this procedure.” Correct

B. “I need to call the doctor if the tubes fall out.” C. “I need to keep his/her ears dry while he’s taking a bath.” D. “I should keep him/her from blowing his nose for 7 to 10 days.” Rationale: The mother’s statement that indicates a need for further instruction is “A fever is normal after this procedure.” The mother should be instructed to report any fever or increased pain, which could indicate a postoperative infection. It is not an emergency if the tubes fall out, but the surgeon should be notified. Nose-blowing should be avoided for 7 to 10 days after the procedure. The child’s ears need to be kept dry during baths and showers. The usual recommendation is to place ear plugs or cotton balls covered with petroleum jelly in the ears during baths and showers. Test-Taking Strategy: Focus on the subject , myringotomy with insertion of tympanostomy tube. Note the strategic words “ need for further instruction ,” which indicate a negative event query and the need to select the incorrect statement. Recalling that fever is an indication of an infection will direct you to the correct option. Review: homecare after myringotomy Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Ear Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

The mother of a child who underwent myringotomy with the insertion of tympanostomy tubes 1 day ago calls the surgeon’s office and reports to the nurse that the child has a small amount of reddish drainage coming from the ears. What information should the nurse provide to the mother? A. Irrigate the ears gently with warm water B. Bring the child to the surgeon’s office to be checked C. Carefully push the tubes a little farther into the ear canal D. Continue to monitor the drainage, because this is a normal finding Correct Rationale: Information the nurse should provide to the mother is to continue to monitor the drainage, because this is a normal fidning. After myringotomy with insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal for the first few days after surgery, but the mother should report any heavier bleeding or bleeding that occurs after 3 days. Having the surgeon check the child is unnecessary. Irrigating the ears with warm water and pushing the tubes further into the ear canal are inappropriate and could cause harm to the child. Test-Taking Strategy: Focus on the subject , myringotomy performed on a child. Focusing on the type of surgical procedure identified in the question will assist you in eliminating the options that involve irrigating the ear and pushing the tubes farther in. To select from the remaining options, note the strategic words “ small amount ” in the question, which should direct you to the correct option.

Review: findings after myringotomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Ear Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Awarded 98.0 points out of 98.0 possible points.

A child has been found to have pharyngitis. The most reliable method of determining whether the infection is bacterial or viral in origin is by which method? A. Throat culture Correct B. The rapid streptococcal antigen test C. Monitoring for complaints of a sore throat D. Collecting data regarding the child’s signs and symptoms origin is a throat culture. Not all children with pharyngitis complain of a sore throat, particularly if they are of preschool age. Instead, the child may complain of a stomachache or simply refuse to eat. Although a rapid streptococcal antigen test can be used to screen for group A streptococcal infection, it is not the most reliable means of determining whether a case of pharyngitis is viral or bacterial in origin. This test has an approximately 20% incidence of false- negative results. Test-Taking Strategy: Focus on the subject , difference between viral and bacterial pharyngitis. Eliminate the options that are comparable or alike in that they involve signs/symptoms. To select from the remaining options, note the strategic words “ most reliable method .” This indicates the best method to differentiate between the two conditions, and direct you to the correct option. Review: tests for pharyngitis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Evidence, Infection HESI Concepts: Evidence-Based Practice/Evidence , Infection Awarded 98.0 points out of 98.0 possible points.

A nurse is caring for a child scheduled for a tonsillectomy. To reduce the risk of aspiration during surgery the nurse should assess the child for which? A. Loose teeth Correct B. Throat redness C. Signs of active infection D. Exudate in the tonsillar area the most reliable means of determining whether a case of pharyngitis is viral or bacterial in Rationale: Although signs/symptoms differ between viral and bacterial pharyngitis,

Rationale: In the preoperative period, the child is checked for loose teeth to reduce the risk of aspiration during surgery. Throat redness and exudate in the tonsillar area are signs/symptoms of active infection. Other signs/symptoms of active infection include fever and an increased white blood cell count. Test-Taking Strategy: Focus on the subject , reducing the risk of aspiration. Note the options that are comparable or alike. Throat redness and exudate in the tonsillar area are signs/symptoms of active infection. Review: preoperative tonsillectomy care of child Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is assessing a child after tonsillectomy. Which finding is indicative of postoperative bleeding? A. Slowed pulse rate B. Frequent swallowing Correct C. Complaints of throat pain D. An increase in blood pressure Rationale: Monitoring the child for postoperative bleeding is most important. Because the operative site in this procedure is not as readily visible as other surgical sites, the nurse must be alert to excessive or frequent swallowing, an increased pulse and decreasing blood pressure, signs/symptoms of fresh bleeding in the back of the throat, vomiting of bright-red blood, and restlessness that does not seem to be associated with pain. Pain is not an indication of postoperative bleeding. Test-Taking Strategy: Focus on the subject , signs/symptoms of postoperative bleeding. Throat pain would be expected in the postoperative period, so eliminate this option. Thinking about the physiological response that occurs with blood loss will assist you in eliminating a slowed pulse rate and an increased blood pressure. Review: bleeding after tonsillectomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Child Health—Throat and Respiratory Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting Awarded 98.0 points out of 98.0 possible points.

In order to facilitate drainage, which position should the nurse place the child who has just undergone a tonsillectomy?

A. Prone Correct B. Supine C. High Fowler D. Semi-Fowler Rationale: After tonsillectomy, the child should be placed in a prone or side-lying position to facilitate drainage. The supine, high Fowler and semi-Fowler positions will not facilitate drainage and may, in fact, increase the risk for aspiration. Test-Taking Strategy: Focus on the subject , a way to facilitate drainage. Visualize each of the positions identified in the options to determine which will facilitate drainage. This will direct you to the correct option. Review: child after tonsillectomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health—Throat and Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is providing discharge dietary instructions to the mother of a child who has undergone tonsillectomy. Which items should the nurse tell the mother are safe to give the child? Select all that apply. A. Water Correct B. Dark toast C. Cherry gelatin D. Scrambled eggs Correct E. Mashed potatoes Correct Rationale: Adequate fluid and food intake promotes healing and maintains hydration. Clear, cool liquids are encouraged. Water will maintain hydration. Soft foods such as mashed potatoes and scrambled eggs will not irritate the throat. Red liquids and foods, such as cherry gelatin, are avoided because they will give the appearance of blood if the child vomits. Rough foods such as toast could irritate the throat. Test-Taking Strategy: Focus on the subject , safe foods following tonsillectomy. Visualizing the anatomical location of the surgical procedure and recall that foods that are rough will irritate the throat. Also remember that red liquids and foods are avoided in the postoperative period. Review: postoperative care of child after tonsillectomy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Throat and Respiratory Giddens Concepts: Client Education, Nutrition HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition Awarded 98.0 points out of 98.0 possible points.

A nurse provides home care instructions to the parents of a child with acute spasmodic croup. What action should the nurse tell the parents to take if stridor at rest occurs? A. Administer an analgesic B. Take the child to the emergency department Correct C. Place a cool-mist humidifier in the child’s room D. Provide mist from steam produced by hot running water in a closed bathroom moderate to severe retractions and children who are unable to take oral fluids should be seen in the emergency department, because these manifestations may indicate airway obstruction. An analgesic will not alleviate the stridor. Although a cool-mist humidifier and steam produced by hot running water are measures used to treat acute spasmodic croup, they are not useful in this situation, which involves stridor, indicating airway obstruction and representing a medical emergency. Test-Taking Strategy: Focus on the subject , stridor at rest. Recalling that stridor is an indication of airway obstruction will direct you to the correct option. Review: complications of acute spasmodic croup Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health—Throat and Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/Gas Exchange, Safety Awarded 98.0 points out of 98.0 possible points.

A nurse is admitting a child with respiratory syncytial virus (RSV) infection to the hospital. The nurse tells the parents that the best way to prevent the spread of the infection is to implement which measure? A. Restricting visitors B. Wearing goggles and a mask C. Washing the hands meticulously Correct D. Wearing goggles and a protective gown Rationale: RSV infection is usually transferred on inadequately washed hands. Meticulous handwashing decreases the spread of organisms. RSV is easily communicable, and is acquired mainly through contact with contaminated surfaces. RSV can live on skin or paper for as long as 1 hour and on cribs and other nonporous surfaces for as long as 6 hours. Maintaining contact precautions (e.g., wearing a gown and gloves) reduces nosocomial transmission of RSV. RSV infection is not airborne, so goggles and masks are unnecessary. Restriction of visitors is not necessary. Test-Taking Strategy: Focus on the subject , prevention of spread of RSV. Note the strategic word “ best .” This indicates the most effective way to prevent the spread of this infection. Recalling the basic principles of standard precautions and remembering that RSV is acquired mainly through contact with contaminated surfaces will direct you to the correct option. Rationale: Children who experience stridor at rest, cyanosis, severe agitation or fatigue, or