Deck 37: Principles and Procedures for Nursing Care of Children

Question 1

What is appropriate to include in the teaching plan for a family of a child with a tracheostomy?

A) Suction the tracheostomy as needed.
B) Apply powder around the stoma to decrease irritation.
C) Limit suctioning time to 30 seconds.
D) Provide showers and discourage baths.

Answer 1

Suction the tracheostomy as needed.

Question 2

An important nursing consideration when performing a bladder catheterization on a young child 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.

Answer 2

insert 2% lidocaine lubricant into the urethra.

Question 3

Which action by the nurse is appropriate when preparing a child for a procedure?

A) Discourage the child from crying during the procedure.
B) Use professional terms so the child will understand what is happening.
C) Give the child choices whenever possible.
D) Discourage the parents from staying in the room during the procedure.

Answer 3

Give the child choices whenever possible.

Question 4

A parent asked,"When should I start dental care for my child?" What response by the nurse is best?

A) "The recommendation is for children to have a dental examination no later than 2.5 years."
B) "Children should see a dentist at least one time before kindergarten."
C) "The recommendation is for children to have a dental examination before first grade."
D) "A dental examination by 1 year of age is the current recommendation."

Question 5

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

A) The oxygen flow rate should be 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.

Question 6

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) use an alcohol-based hand rub.
D) apply new gloves before touching the next patient.

Question 7

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.

Question 8

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."

Question 9

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 I'll have someone hold you down. This is not going to hurt."
B) "This will hurt like a pinch. I'll 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) "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon."

Question 10

Which action is appropriate to promote a toddler's nutrition during hospitalization?

A) Allow the child to walk around during meals.
B) Require the child to empty his or her plate.
C) Ask the child's parents to bring a cup and utensils from home.
D) Select new foods for the child from the menu.

Question 11

A parent calls the pediatrician's office because her 1-year-old child has a 100° F temperature.What is the most appropriate initial nursing response to make to the parent?

A) "Did you feel your child's forehead?"
B) "Does your child appear to be uncomfortable?"
C) "Has anyone in your home been sick lately?"
D) "Don't worry if the temperature is less than 101° F."

Question 12

Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler?

A) Measuring oral temperature for 5 minutes
B) Counting apical heart rate for 60 seconds
C) Observing chest movement for respiratory rate
D) Recording blood pressure as P/80

Question 13

What is critical for the nurse to know 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 integrity.

Question 14

The nurse knows that measuring temperature is an integral part of assessment.Which concept is important for the nurse to know when taking a child's temperature?

A) The method used should be consistent.
B) Rectal temperatures should always be taken on infants.
C) Oral temperatures can be taken on all children older than 5 years of age.
D) Axillary temperatures should be taken at night.

Question 15

A nurse is teaching parents how to care for a child's gastrostomy tube at home.What information should the nurse include?

A) Bring the child to the clinic for cleaning
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.

Question 16

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) wait 10 minutes after applying EMLA cream.
C) restrain child only as needed to perform venipuncture safely.
D) have the parents choose the child's favorite bandage afterward.

Question 17

Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of immunosuppression?

A) Spiritual distress
B) Social isolation
C) Deficient diversional activity
D) Sleep deprivation

Question 18

The nurse is planning how to 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 child's view.
D) using correct scientific and medical terminology in explanations.

Question 19

Which nursing action is most appropriate when treating a child who has a fever of 102.5° F (39.1° C)?

A) Restrict fluid intake.
B) Administer an aspirin.
C) Administer acetaminophen.
D) Bathe the child in tepid water.

Question 20

The nurse is preparing a 12-year-old girl for a bone marrow aspiration.She tells the nurse she wants her mother with her "like before." Which response by the nurse is most appropriate?

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.

Question 21

A toddler's temperature is 101.5° F (38.6° C)axillary.The physician has ordered acetaminophen 10 mg/kg every 4 to 6 hours.The child weighs 22 lb.The bottle of acetaminophen available is a suspension (160 mg/5 mL).______
How much should the nurse administer? Round to the nearest milliliter.

Question 22

A parent wants to know why acetaminophen should only be given for 2 days for a fever without checking with the provider.What response by the nurse is best?

A) Acetaminophen is a dangerous drug with bad side effects.
B) Long-term acetaminophen use can cause liver damage.
C) There may be better fever relievers you could use.
D) What if there were something seriously wrong with your child?

Question 23

In preparing to give enemas to a 4-year-old child,what action by the nurse is best?

A) Use tap water.
B) Only use normal saline.
C) Insert the tip of the tube at least 3 inches.
D) Instill 120 to 240 mL of solution.

Question 24

A student nurse in the emergency department is preparing to obtain a throat culture on a child with suspected epiglottis secondary to a strep infection.What action by the registered nurse is best?

A) Remind the student to wear personal protective equipment.
B) Tell the student to get the child to say "ahhh."
C) Consult with the provider prior to obtaining the culture.
D) Inform the parents and child that a throat culture is needed.

Question 25

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

A) Catheterized urine collection
B) IV line insertion
C) Oxygen administration
D) Lumbar puncture
E) Bone marrow aspiration