Deck 45: Pediatric Variations of Nursing Interventions

Question 1

The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child,the nurse should:

A)Ask the group,"Who is Sam Hart?"
B)Call out to the group,"Sam Hart?"
C)Ask each child,"What's your name?"
D)Check the patient's identification name band.

Answer 1

Check the patient's identification name band.

Question 2

The nurse gives an injection in a patient's room. What should the nurse do with the needle for disposal?

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.

Answer 2

Dispose of syringe and needle in a rigid,puncture-resistant container in patient's room.

Question 3

The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should:

A)Ask him to be quieter.
B)Have his mother tell him to relax.
C)Tell him it is okay to cry and scream.
D)Suggest that he talk to his mother instead of crying.

Answer 3

Tell him it is okay to cry and scream.

Question 4

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)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 5

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. The most appropriate way to collect small amounts of urine for these tests is to:

A)Apply a urine-collection bag to 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 6

The nurse is caring for an unconscious child. Skin care should include:

A)Avoiding use of pressure reduction on the bed.
B)Massaging reddened bony prominences to prevent deep tissue damage.
C)Using draw sheet 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 7

Katie,4 years old,is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her,but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to:

A)Allow her to wear her underpants.
B)Discuss with her mother why this is important to Katie.
C)Ask her mother to explain to her why she cannot wear them.
D)Explain in a kind,matter-of-fact manner that this is hospital policy.

Question 8

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

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 9

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)Rinse gloves in disinfectant solution.
D)Apply new gloves before touching the next patient.

Question 10

A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this:

A)Is unsafe.
B)May help the child relax.
C)Is against hospital policy.
D)Is unnecessary because of the child's age.

Question 11

Kimberly,age 3 years,has a fever associated with a viral illness. Her mother calls the nurse,reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse's action should be based on knowing that:

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 12

Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should:

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 13

An 8-month-old infant is restrained to prevent interference with the intravenous infusion. The nurse should:

A)Remove the restraints once a day to allow movement.
B)Keep the restraints on constantly.
C)Keep the restraints secure so infant remains supine.
D)Remove restraints whenever possible.

Question 14

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her "like before." The most appropriate nursing action is to:

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 15

An appropriate intervention to encourage food and fluid intake in a hospitalized child is to:

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 16

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 17

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

Question 18

In some genetically susceptible children anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that,in addition to an increased temperature,an early sign of this disorder is:

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

Question 19

The Allen test is performed as a precautionary measure before which procedure?

A)Heel stick
B)Venipuncture
C)Arterial puncture
D)Lumbar puncture

Question 20

The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include to:

A)Plan for a short teaching session of about 30 minutes.
B)Tell the child that procedures are never a form of punishment.
C)Keep equipment out of the child's view.
D)Use correct scientific and medical terminology in explanations.

Question 21

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.
Check the placement of the tube by aspirating stomach contents.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 22

The nurse is teaching a mother how to perform chest physiotherapy and postural drainage on her 3-year-old child,who has cystic fibrosis. To perform percussion the nurse should instruct her to:

A)Cover the skin with a shirt or gown before percussing.
B)Strike the chest wall with a flat-hand position.
C)Percuss over the entire trunk anteriorly and posteriorly.
D)Percuss before positioning for postural drainage.

Question 23

An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with:

A)A bottle of formula or milk.
B)Any food the child is going to eat.
C)A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.
D)Large amounts of water to dilute medication sufficiently.

Question 24

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.
Tape the nasogastric tube securely to the child's face.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 25

When caring for a child with an intravenous infusion,the nurse should:

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

Question 26

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.
Place the child in the supine position with head slightly hyperflexed.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 27

When teaching a mother how to administer eye drops,where should the nurse tell her to place them?

A)In the conjunctival sac that is formed when the lower lid is pulled down
B)Carefully under the eye lid 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 28

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 29

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.
Lubricate the nasogastric tube with water-soluble lubricant.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 30

Guidelines for intramuscular administration of medication in school-age children include to:

A)Inject medication as rapidly as possible.
B)Insert the needle quickly,using a dartlike 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 31

The advantages of the ventrogluteal muscle as an injection site in young children include (choose 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 pounds
D)Increased subcutaneous fat,which increases drug absorption
E)Easily identified by major landmarks

Question 32

A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. What 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 33

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.
Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid process and the umbilicus.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 34

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.
Insert the nasogastric tube through the nares.

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 ear lobe to midpoint between the xiphoid process and the umbilicus.

Question 35

It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible can cause:

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

Question 36

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

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

Question 37

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 administer by bottle
D)Keeping the child upright with the nasal passages blocked for a minute after administration

Question 38

The nurse must suction a child with a tracheostomy. Interventions should include:

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