The nurse is giving preoperative instructions to a 14-year-old female client who is
scheduled for surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A. "I will read all the literature you gave me before surgery."
B. "I have had surgery before when I broke my wrist in a bike accident, so I know what
to expect."
C. "All the things people have told me will help me take care of my back."
D. "I understand that I will be in a body cast and I will show you how you taught me to
turn." - Answer -D. "I understand that I will be in a body cast and I will show you how
you taught me to turn."
To take the vital signs of a 4-month-old child, which order will give the most accurate
results?
A. Respiratory rate, heart rate, then rectal temperature.
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate.
D. Rectal temperature, respiratory rate, then heart rate. - Answer -A. Respiratory rate,
heart rate, then rectal temperature.
During routine screening at a school clinic, an otoscope examination of a child's ear
reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable.
What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a healthcare
provider as soon as possible.
D. Call the parents and have them take the child home from school for the rest of the
day. - Answer -B. Ask the child if he/she has had a cold, runny nose, or any ear pain
lately.
Which restraint should be used for a toddler after a cleft palate repair?
A. Clove hitch.
B. Mummy.
C. Elbow.
D. Jacket. - Answer -C. Elbow.
,What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis?
A. Monitor for signs of metabolic acidosis.
B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting. - Answer -D. Observe for projectile vomiting.
A six-month-old returns from surgery with elbow restraints in place. What nursing care
should be included when caring for any restrained child?
A. Keep restraints on at all times.
B. Remove restraints one at a time and provide range of motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Renew the healthcare provider's prescription for restraints every 72 hours. - Answer -
B. Remove restraints one at a time and provide range of motion exercises.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical
examination. The nurse knows which problem is frequently associated with Down
syndrome?
A. Congenital heart disease.
B. Fragile X chromosome.
C. Trisomy 13.
D. Pyloric stenosis. - Answer -A. Congenital heart disease.
When assessing a child with asthma, the nurse should expect intercostal retractions
during
A. Inspiration.
B. Coughing.
C. Apneic episodes.
D. Expiration. - Answer -A. Inspiration.
When planning the care for a child who has had a cleft lip repair, the nurse knows that
crying should be minimized because it
A. Increases salivation.
B. Increases the respiratory rate.
C. Leads to vomiting.
D. Stresses the suture line. - Answer -D. Stresses the suture line.
A full-term infant is admitted to the newborn nursery. After careful assessment, the
nurse suspects that the infant may have an esophageal atresia. Which symptoms is this
newborn likely to have exhibited?
A. Choking, coughing, and cyanosis.
B. Projectile vomiting and cyanosis.
C. Apneic spells and grunting.
D. Scaphoid abdomen and anorexia. - Answer -A. Choking, coughing, and cyanosis.
Which behavior would the nurse expect a two-year-old child to exhibit?
, A. Build a house with blocks.
B. Ride a tricycle.
C. Display possessiveness of toys.
D. Look at a picture book for 15 minutes. - Answer -C. Display possessiveness of toys.
The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto
Bismol to her son when he "has a tummy ache." After reminding the mother to check
the label of all over-the-counter drugs for the presence of aspirin, which instruction
should the nurse include when replying to this mother's question?
A. If the child's tongue darkens, discontinue the Pepto Bismol immediately.
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
C. Avoid the use of Pepto Bismol until the child is at least 16 years old.
D. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache." -
Answer -B. Do not give if the child has chickenpox, the flu, or any other viral illness.
The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the
nurse consider normal for this child?
A. Has a temper tantrum when told he must share his toys.
B. Plays by himself most of the day.
C. Demonstrates aggressiveness by boasting when telling a story.
D. Begins to cry and is fearful when separated from his parents. - Answer -C.
Demonstrates aggressiveness by boasting when telling a story.
A burned child is brought to the emergency room. In estimating the percentage of the
body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is
calculated as a larger percentage of total body surface than an adult's?
A. Head and neck.
B. Arms and chest.
C. Legs and abdomen.
D. Back and abdomen. - Answer -A. Head and neck.
The nurse receives a lab report stating a child with asthma has a theophylline level of
15 mcg/dl. What action will the nurse take?
A. Pass the information on in the report.
B. Notify the healthcare provider because the value is high.
C. Repeat the lab study because the value is too high.
D. Hold the next dose of theophylline. - Answer -A. Pass the information on in the
report.
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He
is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority
for this infant?
A. Give small, frequent feedings of fluids.
B. Accurately chart observations regarding breath sounds.
C. Have a bulb syringe readily available to remove secretions.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller millyphilip. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.