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After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?
1. Maintain NPO status.
2. Turn the child to the side.
3. Administer the prescribed antiemetic.
4. Notify the health care provider (HCP).
2. Turn the child to the side.
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The nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review?
1. Creatinine level
2. Prothrombin time
3. Sedimentation rate
4. Blood urea nitrogen level
2. Prothrombin time
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The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?
1. Supine
2. Side-lying
3. High Fowler's
4. Trendelenburg's
2. Side-lying
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After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question?
1. Monitor for bleeding.
2. Suction every 2 hours.
3. Give no milk or milk products.
4. Give clear, cool liquids when awake and alert.
2. Suction every 2 hours.
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The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?
1. Frequent swallowing
2. A decreased pulse rate
3. Complaints of discomfort
4. An elevation in blood pressure
1. Frequent swallowing
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A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?
1. Warm, dry skin
2. Decreased wheezing
3. Pulse rate of 90 beats/minute
4. Respirations of 18 breaths/minute
2. Decreased wheezing
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The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother?
1. Increase the dose of ibuprofen.
2. Increase the frequency of ibuprofen.
3. Encourage the child to lie on the left side.
4. Encourage the child to lie on the right side.
4. Encourage the child to lie on the right side.
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A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?
1. Side or prone
2. Back or prone
3. Stomach with the face turned
4. Back rather than on the stomach
4. Back rather than on the stomach
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The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?
1. "The immunization schedule will need to be altered."
2. "The child should not receive any hepatitis vaccines."
3. "The child will receive all the immunizations except for the polio series."
4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
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The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?
1. The child exhibits nasal flaring and bradycardia.
2. The child is leaning forward, with the chin thrust out.
3. The child has a low-grade fever and complains of a sore throat.
4. The child is leaning backward, supporting himself or herself with the hands and arms.
2. The child is leaning forward, with the chin thrust out.
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A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?
1. Tell the mother that the child must stay in the tent.
2. Place a toy in the tent to make the child feel more comfortable.
3. Call the health care provider and obtain a prescription for a mild sedative.
4. Let the mother hold the child and direct the cool mist over the child's face.
4. Let the mother hold the child and direct the cool mist over the child's face.
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The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?
1. Positive
2. Negative
3. Inconclusive
4. Definitive and requiring a repeat test
1. Positive
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The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?
1. "The child may be allergic to antibiotics."
2. "The child is too young to receive antibiotics."
3. "Antibiotics are not indicated unless a bacterial infection is present."
4. "The child still has the maternal antibodies from birth and does not need antibiotics."
3. "Antibiotics are not indicated unless a bacterial infection is present."
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The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
1. Initiate strict enteric precautions.
2. Move the infant to a room with another child with RSV.
3. Leave the infant in the present room because RSV is not contagious.
4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.
2. Move the infant to a room with another child with RSV.
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The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.
1. Place the infant in a private room.
2. Ensure that the infant's head is in a flexed position.
3. Wear a mask at all times when in contact with the infant.
4. Place the infant in a tent that delivers warm humidified air.
5. Position the infant on the side, with the head lower than the chest.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
- 1. Place the infant in a private room.
- 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
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A child is scheduled for a tonsillectomy. A nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery?
1. Presence of loose teeth
2. Bleeding during surgery
3. Difficulty in swallowing
4. Exudate in the throat area
1. Presence of loose teeth
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A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate?
1. "The child probably has an infection."
2. "Have the child gargle with mouthwash every 4 hours."
3. "You need to contact the health care provider immediately."
4. "Bad mouth odor is normal and may be relieved by drinking more liquids."
4. "Bad mouth odor is normal and may be relieved by drinking more liquids."
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An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse should place which instruction(s) on the list? Select all that apply.
1. Avoid hot fluids.
2. Avoid raw vegetables.
3. Consume pudding products.
4. Rest in bed or on a couch for 24 hours.
5. Drink fruit smoothies to soothe the throat.
- 1. Avoid hot fluids.
- 2. Avoid raw vegetables.
- 4. Rest in bed or on a couch for 24 hours.
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The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child?
1. Cola with ice
2. A glass of milk
3. Cool cherry Kool-Aid
4. Yellow noncitrus Jell-O
4. Yellow noncitrus Jell-O
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A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the health care provider, should the nurse question?
1. Obtain a throat culture.
2. Obtain axillary temperatures.
3. Administer humidified oxygen.
4. Administer acetaminophen (Tylenol) for fever.
1. Obtain a throat culture.
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The student nurse is caring for an infant with a tracheostomy and preparing to suction the infant. The nursing instructor should intervene if the nursing student stated she would take which action to perform this procedure?
1. Limit insertion and suctioning time to 15 seconds to prevent hypoxia.
2. Insert the catheter the length of the tracheostomy tube with the suction off.
3. Apply intermittent suction and withdraw the catheter with a twisting motion.
4. Reoxygenate between suction catheter passage, and allow sufficient recovery time with each pass.
1. Limit insertion and suctioning time to 15 seconds to prevent hypoxia.
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Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis (CF). What instruction should the nurse include in the client's teaching plan?
1. Schedule the procedures so they are 4 hours apart.
2. Perform the breathing exercises and then the postural drainage.
3. Perform the postural drainage first and then the breathing exercises.
4. Perform postural drainage in the morning and breathing exercises in the evening.
3. Perform the postural drainage first and then the breathing exercises.
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A school nurse is teaching parents about emergency treatment for epistaxis. Which best action should the nurse take to assist the parents in understanding the emergency treatment?
1. Tell the parents the steps to take when a nosebleed occurs.
2. Show the parents a video of the steps to take if a nosebleed occurs.
3. Give the parents a brochure about the emergency treatment for nosebleeds.
4. Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs.
4. Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs.
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A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan?
1. Oral antibiotics
2. Supportive treatment
3. IV fluid administration
4. Hospitalization and intravenous (IV) antibiotics
2. Supportive treatment
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The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF?
1. Transmitted as an autosomal dominant trait
2. A chronic multisystem disorder affecting the exocrine glands
3. A disease that causes the formation of multiple cysts in the lungs
4. A disease that causes dilation of the passageways of many organs
2. A chronic multisystem disorder affecting the exocrine glands
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A mother calls the pediatrician's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother?
1. "Is your child crying and irritable?"
2. "Does your child have a productive cough?"
3. "Did he have a temperature last night of greater than 100° F?"
4. "Is your child telling you at this time he is having trouble breathing?"
4. "Is your child telling you at this time he is having trouble breathing?"
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The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?
1. Positive
2. Negative
3. Inconclusive
4. Definitive and requiring a repeat test
2. Negative
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After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position?
1. Prone
2. Supine
3. High Fowler's
4. Trendelenburg
1. Prone
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A nurse is assisting in developing a plan of care for a child following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?
1. Supine
2. Side-lying
3. High-Fowler's
4. Trendelenburg
2. Side-lying
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A pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which item should the nurse offer to the child?
1. Cola with ice
2. Green gelatin
3. A glass of milk
4. Cherry Kool-Aid
2. Green gelatin
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A nurse is reviewing the health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question?
1. Suction the child frequently if coughing.
2. Discharge to home when alert and tolerating fluids.
3. Provide clear cool liquids to the child when awake.
4. Instruct the parent not to give the child milk products.
1. Suction the child frequently if coughing.
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During clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about cystic fibrosis?
1. CF causes mucus that is formed to be abnormally thick.
2. It is a condition transmitted as an autosomal recessive trait.
3. This disease causes dilation of the passageways of many organs.
4. It is a chronic multisystem disorder affecting the exocrine glands.
3. This disease causes dilation of the passageways of many organs.
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The nurse reviews the health record of a 2-year-old child. The health care provider has documented that the results of a tuberculin skin test have indicated an area of induration measuring 5 mm. How should the nurse interpret these results?
1. Positive
2. Negative
3. Inconclusive
4. Requires a repeat test
2. Negative
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A nurse has provided instructions to the mother of a child with cystic fibrosis (CF) about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures?
1. "The diet needs to be low in fat."
2. "The diet needs to be low in protein."
3. "The diet needs to be low in calories."
4. "The diet needs to be high in calories."
4. "The diet needs to be high in calories."
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A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant?
1. Supine, side-lying position with the arms elevated
2. Prone with the head of the bed elevated 15 degrees
3. Trendelenburg, at a 60-degree angle with pelvis higher than head
4. Head and chest at a 30-degree angle with the neck slightly extended
4. Head and chest at a 30-degree angle with the neck slightly extended
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A nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching?
1. "I should place a steam vaporizer in my child's room."
2. "I will take my child out into the cool, humid night air."
3. "I could place a cool mist humidifier in my child's room."
4. "I will have my child inhale the steam from warm running water."
1. "I should place a steam vaporizer in my child's room."
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The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding?
1. Extreme fatigue
2. The presence of pain
3. An airway obstruction
4. The presence of dehydration
3. An airway obstruction
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A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome (SIDS). The student plans to write on a handout that it isbest to place an infant in which position for sleep?
1. On the back, or prone
2. On the back, or supine
3. On the stomach, or prone
4. On the stomach, or supine
2. On the back, or supine
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