Deck 39: Pediatric Variations of Nursing Interventions

Question 1

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."

Answer 1

"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."

Question 2

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 infant's tongue.
B) Administering the medication as rapidly as possible with the infant securely restrained.
C) Mixing the medication with the infant's regular formula or juice and administering by bottle.
D) Keeping the child upright with the nasal passages blocked for a minute after administration.

Answer 2

Administering the medication with a syringe (without needle) placed along the side of the infant's tongue.

Question 3

The nurse monitoring a child for signs and symptoms of malignant hyperthermia should be alert for which early sign of this disorder?

A) Apnea
B) Bradycardia
C) Muscle rigidity
D) Decreased blood pressure

Answer 3

Muscle rigidity

Question 4

The nurse is caring.What skin care interventions for an unconscious child should be included in the plan of care?

A) Avoiding use of pressure reduction on the bed.
B) Massaging reddened bony prominences to prevent deep tissue damage.
C) Using drawsheet 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.

Question 5

What is an appropriate intervention to encourage food and fluid intake in a hospitalized child?

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.

Question 6

Guidelines for intramuscular administration of medication in school-age children include what instruction?

A) Inject medication as rapidly as possible.
B) Insert the needle quickly, using a dart-like 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.

Question 7

The nurse gives an injection in a patient's room.Which method should the nurse use to dispose of the needle?

A) Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room.
B) Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patient's 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.

Question 8

A 3 year old has a 102° F fever associated with a viral illness that has not responded to acetaminophen.The nurse's action should be based on what knowledge about fevers in children?

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.

Question 9

The nurse wore gloves during a dressing change.When the gloves are removed,the nurse should perform which initial action?

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.

Question 10

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 11

What is an important nursing consideration when performing a bladder catheterization on a young boy?

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.

Question 12

The nurse is cleaning multiple facial abrasions on a 9-year-old who was brought to the emergency department by his/her mother.When the child begins crying and screaming loudly,what intervention should the nurse implement to best manage this situation?

A) Calmly ask the child to be quieter.
B) Suggest that his/her mother help the child to relax.
C) Tell the child it is okay to cry and scream.
D) Suggest that he/she talk to his/her mother as a form of distraction.

Question 13

What intervention is appropriate when administering tepid water or sponge baths prescribed for hyperthermia in children?

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.

Question 14

Using knowledge of child development,what is the best approach when preparing a toddler for a procedure?

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.

Question 15

What important consideration in providing atraumatic care should the nurse consider when preforming a venipuncture on a 6-year-old child?

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.

Question 16

When teaching a mother how to administer eyedrops,where should the nurse instruct 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 eye's surface.

Question 17

The most appropriate nursing action to implement when a preschooler being prepped for outpatient surgery refused to allow the parent to remove his/her underwear?

A) Allow the child to wear their underpants.
B) Discuss to the mother why this is important.
C) Ask the mother to explain to her child why he/she must remove the underwear.
D) Explain in a kind, matter-of-fact manner that this is hospital policy.

Question 18

The nurse administering a bitter oral medication to an infant or small child should mix the medication with what substance?

A) A bottle of formula or milk.
B) Any food the child is going to eat.
C) A teaspoon of jam or ice cream.
D) Large amounts of water to dilute medication sufficiently.

Question 19

The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures.What guideline should the nurse consider when preparing a preschooler for a diagnostic procedure?

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 20

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant.How should the nurse collect small amounts of urine for these tests?

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.

Question 21

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
B) 300 mL
C) 350 mL
D) 400 mL

Question 22

After collecting blood by venipuncture in the antecubital fossa,what intervention should the nurse implement in order to assure control of any bleeding?

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.

Question 23

What nursing consideration is related to the administration of oxygen (O₂)in an infant?

A) Humidify the oxygen if the infant can tolerate it.
B) Assess the infant to determine how much oxygen should be given.
C) Arterial oxygen saturation (SaO₂) readings are used to guide O₂ therapy.
D) Direct the oxygen flow so that it blows directly into the infant's face in a hood.

Question 24

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 lbs
D) Increased subcutaneous fat, which increases drug absorption
E) Easily identified by major landmarks

Question 25

A 2-year-old child comes to the emergency department demonstrating signs of dehydration and hypovolemic shock.Which 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.

Question 26

Which is the preferred site for intramuscular injections in infants?

A) Deltoid
B) Dorsogluteal
C) Rectus femoris
D) Vastus lateralis

Question 27

When caring for a child with an intravenous infusion,the nurse should include which intervention in the plan of care?

A) Using a macrodropper to facilitate reaching the prescribed flow rate.
B) Avoid restraining the child to prevent undue emotional stress.
C) Changing the insertion site every 24 hours.
D) Observing the insertion site frequently for signs of infiltration.

Question 28

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.

Step one

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.

Question 29

It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible increases the risk of which injury?

A) Hyperthermia
B) Electrocution
C) Pressure necrosis
D) Burns under sensors

Question 30

What procedure is recommended to facilitate a heelstick on an ill neonate to obtain a blood sample?

A) Apply cool, moist compresses.
B) Apply a tourniquet to the ankle.
C) Elevate the foot for 5 minutes.
D) Wrap foot in a warm washcloth.

Question 31

What intervention should the nurse implement when suctioning a child with a tracheostomy?

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 10 seconds.
D) Allowing the child to rest after every 5 times the suction catheter is passed.

Question 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.

Question 33

Which nursing action is the most appropriate when applying a face mask to a child prescribed 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.

Question 34

When administering a gavage feeding to a school-age child,the nurse should implement what intervention to assure safety?

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.

Question 35

What information should the nurse include when teaching parents how to care for a child's 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.

Question 36

In preparing to give "enemas until clear" to a young child,the nurse should select which solution?

A) Tap water
B) Normal saline
C) Oil retention
D) Fleet solution

Question 37

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) Bone marrow aspiration

Question 38

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

Question 39

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.

Question 40

What critical information should the nurse incorporate into 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.

Question 41

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.

Step five

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.

Question 42

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.

Step two

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.

Question 43

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.

Step six

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.

Question 44

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.

Step three

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.

Question 45

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.

Step four

A)Lubricate the nasogastric tube with water-soluble lubricant.
B)Tape the nasogastric tube securely to the child's 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.