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Question
A supervisor is reviewing the documentation of the nurses in the unit. The documentation that most accurately and correctly contains all the required parts for a narrative entry is the entry that reads:
1. "1630 catheterized using an 8 French catheter, 45 ml clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mother's arms following catheter removal. M. May RN"
2. "1/9/05 2 p.m. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10 ml residual stomach contents returned to stomach, PediaSure formula hung on Kangaroo pump infusing at 60 ml/hr for 1 hour. Child grunting intermittently throughout procedure. K. Earnst RN"
3. "Feb. '05 Portacath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globulins hung and infusing at 30 ml/hr. Child smiling and playful throughout the procedure. P. Potter, RN"
4. "4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. F. Luck RN"
Answer
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Related questions
Q:
A three-year-old child is suspected of having Hirschsprung's disease. Which assessment factors would support such a medical diagnosis?
1. Clay-colored stools and dark urine
2. History of early passage of meconium in the newborn period
3. History of chronic, progressive constipation and failure to gain weight
4. Continual bouts of foul-smelling diarrhea
Q:
The 10-year-old boy is admitted to the pediatric neurologic unit with a suspected craniopharyngioma. The nurse will assess the child with which symptoms related to this brain tumor?
Standard Text: Select all that apply.
1. Evening nausea
2. Excessive urination leading to dehydration
3. Nystagmus
4. Headaches
5. Orbital ecchymosis
Q:
The ten-year-old child was diagnosed with a medulloblastoma; following surgery the child is started on chemotherapy by intrathecal injection. While preparing the family for the start of chemotherapy, the nurse will explain that intrathecal administration was chosen because:
1. It reduces side effects.
2. It does not require the child being "stuck."
3. Many chemotherapy drugs do not cross the blood-brain barrier.
4. Intrathecal administration is less expensive than intravenous administration.
Q:
Following diagnosis of osteosarcoma, a 14-year-old girl has a below-the-knee amputation. The girl has had trouble accepting the reality of her amputation. Which behavior, when observed by the nurse, indicates she is beginning to accept the amputation?
1. The girl complains of pain in the missing leg.
2. When physical therapy comes, she is willing to have her temporary prosthetic applied and attempts crutch training.
3. Prior to visiting hours, she asks to be helped to a wheelchair with a blanket over her legs.
4. When the nurses change the dressing on the stump, she watches the dressing change.
Q:
A child has been diagnosed with Ewing sarcoma and is being started on a chemotherapy protocol. The mother questions the nurse on why more than one drug is being used as it would seem that using fewer drugs would decrease the side effects. The best response by the nurse would include the information that:
1. The child's cancer is a severe form and needs additional drugs to remove the cancer.
2. A protocol is a proven means of treatment.
3. A protocol is used in children but not adults due to the chemotherapy's effect on growth.
4. A protocol involves a group of drugs that work in different modes and have different side effects.
Q:
The nurse is explaining to the mother that her child with cancer will receive chemotherapy daily for one month and then no treatments for six weeks. Following the period of rest, chemotherapy will be administered again for another month. The mother asks why the child can"t receive the medication for two months straight. The nurse would explain that the rest period:
1. Prevents the child from having side effects from the drugs.
2. Is due to the scheduling requirements of the infusion center.
3. Is necessary because receiving the medication for more than one month can cause heart failure.
4. Allows normal cells to repair themselves while the cancer cells die.
Q:
During rounds, the interdisciplinary team is discussing the care of a child with a newly diagnosed Wilms' tumor. The nurse describes the mother as being angry and upset that they are not caring properly for her child. What behavior probably is the cause of the mother's anger?
1. The mother is beginning the stages of grief over loss of her previously well child.
2. The mother is feeling guilty for not recognizing that the child was ill.
3. The nurses are negligent in providing safe care for the child.
4. The mother does not have adequate support from Social Services.
Q:
After years of treatment with chemotherapy and radiation, a child with a brain tumor is shown to be refractory to treatment, and a DNR (Do Not Resuscitate) has been obtained. The mother has reached the stage of acceptance; the father is angry that the medical and nursing team has not been able to "save" his child. How would the multidisciplinary team best support this family?
1. Tell the father that he should have brought his child in earlier for treatment.
2. Continue to include the family in planning care and assure them that the child will be kept comfortable in the days to come.
3. Initiate a Social Services referral.
4. Contact the on-call chaplain for consultation with the entire family and ask him to take the father aside for additional assistance.
Q:
The antiemetic drug ondansetron (Zofran) is being administered to a child receiving chemotherapy. It should be administered:
1. Only if the child experiences nausea.
2. Before chemotherapy administration, as a prophylactic measure.
3. After the chemotherapy has been administered.
4. Never; this antiemetic is not effective for controlling nausea and vomiting associated with chemotherapy.
Q:
The physician has ordered the child to receive a unit of packed red blood cells. In preparing to administer the blood, the nurse will initiate an intravenous line and hang what fluid?
1. D5W
2. D5LR
3. D5 1/4NS
4. NS
Q:
The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction may be within the nurse's realm of prevention?
1. Allergic
2. Hemolytic
3. Febrile
4. Septic
Q:
A child who has undergone a hematopoietic stem cell transplantation (HSCT) is ready for discharge. Which concepts are important for the nurse to include in discharge education?
Standard Text: Select all that apply.
1. Keeping the child on a high-calcium diet
2. Practicing good hand washing
3. Avoiding live plants and fresh vegetables
4. Avoiding influenza vaccinations
5. Returning the child to school within six weeks
Q:
For which complication(s) should the nurse observe during administration of Factor VIII to a child with hemophilia?
1. Fever and chills
2. Fat emboli
3. Nausea and vomiting
4. Congestive heart failure
Q:
Which of the following parental demonstrations indicates that the parents understand the nurse's teaching with regard to prevention of iron-deficiency anemia?
1. The parents feed their infant with a formula that is not iron-fortified.
2. The child's vitamin C consumption is limited after one year of age.
3. The parents start iron-fortified infant cereal at four to six months of age.
4. Cow's milk is introduced into the child's diet at six months of age.
Q:
A two-month-old infant has been diagnosed with severe combined immunodeficiency disease (SCID). The physician talked with the parents about the planned treatment and prognosis for the infant. Which statement by the parents indicates the need for additional education?
1. "My child will receive intravenous immune globulins as a way to help him fight infection."
2. "Within days of receiving a stem cell transplant, my child will be cured."
3. "If my child needs a blood transfusion, it should be with irradiated blood cells."
4. "Antibiotics will be used as necessary to help my child fight infections."
Q:
The nurse is preparing the hospital room for admission of a child with multiple allergies including cow's milk, peanuts, and latex. The nurse's priority responsibility in preparing for this child would include:
1. Evaluating the hospital room for equipment containing latex.
2. Ordering an EpiPen for the child.
3. Notifying dietary of the milk and peanut allergy.
4. Placing a sign on the door which identifies all allergies.
Q:
The nurse is caring for a child with rheumatoid arthritis. Which is an appropriate nonpharmacologic measure to reduce the joint pain associated this disease?
1. Elevation of the extremity
2. Immobilization
3. Massage
4. Application of moist heat
Q:
A seven-year-old girl has been diagnosed with rheumatic fever. The physician has talked with the parents and child and explained the disease and the planned medical treatment. Which statement by the parents needs further clarification?
1. "I understand rheumatic fever is a strep infection of the heart."
2. "My child will be on bed rest for several weeks."
3. "My child will be treated with aspirin and/or corticosteroids."
4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease."
Q:
A nine-year-old has been diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. The nurse teaches parents that this disorder is called:
1. Dysgraphia.
2. Dyscalculia.
3. Dyspraxia.
4. Dyslexia.
Q:
The nurse knows that the mother of a six-year-old needs more teaching about her son's diagnosis of ADHD when she states:
1. "I will develop a reward system for desired behaviors."
2. "I will take my child to the physician every three months for a weight and height check."
3. "I will let him do his homework while he is watching his favorite television show."
4. "I will stick to the same routine each day after school."
Q:
When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother?
1. The mother leaves the filled mop bucket on the floor while in another room.
2. The mother turns all pan handles to the back of the stove.
3. The mother fills the bath tub before bringing the baby into the bathroom.
4. When riding in a car, the child is in a car seat in the middle of the back seat.
Q:
A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby?
1. Hypotonia and muscle instability
2. Hypertonia and persistence primitive reflexes
3. Tremors and exaggerated posturing
4. Hemiplegia and hypertonia
Q:
In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to:
Standard Text: Select all that apply.
1. Expect the child to have normal intelligence.
2. Use latex precautions.
3. Allow the child to do her own self-catheterization.
4. Ensure that the child has a low-fiber diet.
5. Encourage the child to shift positions hourly when in her wheelchair.
Q:
A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show:
1. Decreased protein count.
2. Clear, straw-colored fluid.
3. Positive for RBCs.
4. Decreased glucose level.
Q:
The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal?
1. The posterior fontanel is open.
2. The infant has good head control when held upright.
3. The infant is able to roll only from abdomen to back.
4. The anterior fontanel is open and soft.
Q:
During the hospital stay in the newborn nursery, the infant is tested for galactosemia. When the test is positive, the parents are educated about treatment for galactosemia. The infant will be placed on what type of infant feeding?
1. Goat's milk formula
2. Breast milk
3. Cow's milk-based formula
4. Meat-based formula such as Nutramigen
Q:
The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions to minimize pain will the nurse include in the teaching?
Standard Text: Select all that apply.
1. Do not reuse needles.
2. Remove all bubbles from the syringe before injecting.
3. Have the child flex the muscle during injection.
4. Inject insulin when it is cold.
5. Do not change the direction of the needle during insertion or withdrawal.
Q:
A teenager has arrived in the emergency department (ED) with confusion. The physician suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 76l5 mg/dL. The nurse expects that this teen has which symptoms?
1. Tachycardia, dehydration, and abdominal pain
2. Sweating, photophobia, and tremors
3. Dry mucous membranes, blurred vision, and weakness
4. Dry skin, shallow rapid breathing, and dehydration
Q:
The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which of the physician's orders should the nurse question?
1. Neurological checks hourly
2. Insert urinary catheter and measure output hourly.
3. NPH insulin IV at 0.1 units/kg per hour
4. Stat serum electrolytes
Q:
A five-year-old with a history of being treated for hypopituitarism comes to the physician with complaints of right hip and leg pain. The nurse understands that this symptom might be related to which medication that is used to treat hypopituitarism?
1. Daily growth hormone
2. Insulin before meals and bedtime
3. DDAVP (desmopressin acetate) at HS
4. Cortisone injections