Peadritics alresdy graded A+ | Exams Nursing

ATI Capstone Pediatrics Assessment 2 already Graded A

a charge nurse is assisting a newly licensed nurse with the preoperative assessment of

a 2 year old child who has a Wilm's tumor, what actions by the newly licensed nurse

requires intervention from the charge nurse - anspalpating the child's abdomen

a home health nurse is providing teaching about post-seizure management to the

parents of a school-age child who has epilepsy, what should be included - ansrecord

the length and character of the child's postictal period following a seizure

call for emergency medical services if the size of the child's pupils are unequal after the

seizure

a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly

licensed nurse, what statements by the newly licensed nurse indicates an

understanding of the disorder - ansReye's syndrome causes fatty changes in the liver

a nurse in a pediatric clinic is performing a history and physical for a toddler who is

going to receive a MMR immunization, what indicates that it should be withheld -

ansreceiving prednisone for nephrotic syndrome

a nurse in the ED is creating a plan of care for a child who has an acute head injury

following a fall from playground equipment, what interventions should the nurse include

- ansinitiate seizure precautions for the child

a nurse in the emergency department is caring for a preschooler who has epiglottitis ,

what action should the nurse take - ansinitiate droplet precautions for the child

a nurse is admitting a child who has bacterial meningitis, what actions should the nurse

take first - ansinitiate antibiotic therapy for the child

a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery,

what pain measurement tools should the nurse use to determine if the infant is

experiencing pain - ansFLACC

a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental

tasks should be expected - ansuses primarily two word phrases

a nurse is assessing a 5 month year old infant during a well-child visit, what finding

should the nurse report to the provider - ansthe infant does not make consonant sounds

when babbling

a nurse is assessing a 6 month old infant during a well-child visit, what finings should

the nurse report to the provider - ansthe infant does not roll over from his abdomen to

his back

a nurse is assessing a child who has acute renal failure, what clinical manifestations are

expected - ansedema

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a charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2 year old child who has a Wilm's tumor, what actions by the newly licensed nurse requires intervention from the charge nurse - anspalpating the child's abdomen a home health nurse is providing teaching about post-seizure management to the parents of a school-age child who has epilepsy, what should be included - ansrecord the length and character of the child's postictal period following a seizure call for emergency medical services if the size of the child's pupils are unequal after the seizure a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly licensed nurse, what statements by the newly licensed nurse indicates an understanding of the disorder - ansReye's syndrome causes fatty changes in the liver a nurse in a pediatric clinic is performing a history and physical for a toddler who is going to receive a MMR immunization, what indicates that it should be withheld - ansreceiving prednisone for nephrotic syndrome a nurse in the ED is creating a plan of care for a child who has an acute head injury following a fall from playground equipment, what interventions should the nurse include

ansinitiate seizure precautions for the child a nurse in the emergency department is caring for a preschooler who has epiglottitis , what action should the nurse take - ansinitiate droplet precautions for the child a nurse is admitting a child who has bacterial meningitis, what actions should the nurse take first - ansinitiate antibiotic therapy for the child a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery, what pain measurement tools should the nurse use to determine if the infant is experiencing pain - ansFLACC a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental tasks should be expected - ansuses primarily two word phrases a nurse is assessing a 5 month year old infant during a well-child visit, what finding should the nurse report to the provider - ansthe infant does not make consonant sounds when babbling a nurse is assessing a 6 month old infant during a well-child visit, what finings should the nurse report to the provider - ansthe infant does not roll over from his abdomen to his back a nurse is assessing a child who has acute renal failure, what clinical manifestations are expected - ansedema

a nurse is assessing a child who has received the first 50 mL of a blood transfusion, what findings indicates the child may be experiencing an air embolism - anssharp pain in the middle of the chest a nurse is assessing a child who has sickle cell anemia and is experiencing a vasoocclusive crisis, what manifestations should the nurse expect - anspain a nurse is assessing a toddler who has infective endocarditis, what findings should the nurse expect - ansnew heart murmur a nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5/101.3, what findings should the nurse suspect a UTI - ansincontinence a nurse is assessing an infant who has hydrocephalus, what clinical manifestations should the nurse expect - ansseparated cranial sutures a nurse is assessing an infant who has intussusception, what manifestation is expected

ansgelatinous red stool a nurse is caring for a 4m old infant who is immediately postop following cleft palate repair, what intervention should the nurse take - ansapply elbow restraints to the infant a nurse is caring for a an infant who has GERD, what action should the nurse take to avoid regurgitation - ansthicken the pt's formula avoid giving the pt citrus juices position the child with head elevated after meals a nurse is caring for a child who has acute glomerlulonephritis without edema, what action should the nurse take - ansobtain a daily weight a nurse is caring for a child who has bacterial meningitis, what action should the nurse take - ansinitiate seizure precautions a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and take the child home, what responses should the nurse make - anstell me more about your reasons for making this decision today a nurse is caring for a child who has congenital heart defect, the nurse should recognize that which of the following defects is associated with increased pulmonary blood flow - ansPDA a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values provides an explanation for the finding - ansplt count 120,

a nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin, what instruction should the nurse include - anstake the medication at the same time each day a nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate, what instruction should the nurse include - ansadminister the second dose of the medication at lunch time a nurse is providing teaching to the parent of a preschooler about health promotion, what response by the parent indicates an understanding of the teaching - ansi should encourage my child to have 1 hour of physical activity each day a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an understanding of the teaching - ansi should place the car seat rear facing until my child is 2 a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included - anssoak hear brushes in boiling water for 10min a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent - ansTdap a nurse is suctioning the tracheostomy of a child, what assessment findings indicates effectiveness of the procedure - ansclear breath sounds a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines teaching has been effective when they indicate they will provide which of the following when the child is ill - ansincreased fluids a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make - ansyou should put your infant in bed with a pacifier a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include in the teaching - ansestablish a structured daily routine for the child a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following placement of tympanoplasty tubes. the parent asks, what should i do if the tubes fall out. what should the nurse instruct - ansnotify the provider that the tubes have fallen out

a school nurse is assessing a child who fell from playground equipment and landed head-first, what clinical manifestations should the nurse recognize as indicating increased intracranial pressure - ansreport of diplopia a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for strabismus - ansmovement of the uncovered eye during a cover test A 45-year-old client is taking methylprednisolone. What pharmacologic action should the nurse expect with this therapy?

Suppression of beta2 receptors 2)Suppression of airway mucus production
Fortification of bones
Suppression of candidiasis - ans2) Suppression of airway mucus production Corticosteroids, such as methylprenisolone will suppress airway mucus production A 52-year-old client with a history of angina has been prescribed transdermal nitroglycerin. Which of the following adverse effects is not seen with this therapy?
Tolerance
Orthostatic hypotension
Headache
Productive cough - ans4) Productive cough Nitroglycerin therapy does not directly have an effect lung function. Physiologically, vasodilation should effect capillary perfusion and decrease lung secretions A 55-year-old client has levothyroxine ordered. Which of the below past medical history concerns may contraindicate with her medication management of hypothyroidism?
Scleroderma
Osteoporosis
Asthma
Peripheral Vascular Disease - ans2) Osteoprosis There is an increased risk for fracture, especially in older adults A client has been prescribed isosorbide monoitrate. Which of the following should the nurse include in this client's education related to this medication?
This medication is prescribed for long-term therapy prophylaxis against anginal attacks
You can crush this medication if needed
Take the medication in the evening after dinner
Take an additional tablet if you experience chest pain - ans1) This medication is prescribed for long-term prophylaxis against anginal attacks Isosorbide mononitrate is used for long-term prophylaxis against anginal attacks

A nurse has just administered a wrong medication to a client. Which of the following actions should the nurse take next?

No action is needed
Report error to the provider
Complete an institutional incident report
Inform the client that the wrong medication was given - ans2) Report the error to the provider The nurse should acknowledge the error and report it to the provider for further orders. The nurse should also monitor the client for adverse effects. The nurse should also complete an incident report per institutional policy after notifying the health care provider A nurse have provided education to a client regarding prescribed levothyroxene sodium. What of the following client statements demonstrates understanding of medication administration?
"I should take my medication as needed to alleviate symptoms"
"I should take the medication in divided doses to ensure therapeutic drug levels"
"I should take the medication in the morning to prevent insomnia"
"I should take the medication on a full stomach" - ans3) "I should take the medication in the morning to prevent insomnia" Levothyroxene sodium should be taken once in the morning to prevent insomnia A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
Change positions slowly and lie down if dizziness occurs
There is no need to avoid normal activities
Avoid dairy products while taking this medication
Do not eat green leafy vegetables - ans1) Change positions slowly and lie down if dizziness occurs First-dose orthostatic hypotension can occur with doxazosin. The nurse should instruct clients to change position slowly and to lie down if feeling dizzy, lightheaded or faint A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?
anorexia and weakness
hyperactivity and hunger
tachycardia and increased urination
polyphagia and polydipsia - ans1) anorexia and weakness Anorexia, fatigue and weakness are signs of potential digitalis toxicity. GI effects of digitalis toxicity include anorexia, nausea, vomiting, and abdominal pain. CNS effects

include fatigue, weakness, vision changes (diplopia, blurred vision, yellow-green or white halos around objects). Bradycardia is also commonly noted in digitalis toxicity A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?

Take the medication on an empty stomach to maximize absorption
Notify your provider if your stool becomes dark green
Decrease dietary fiber intake while taking this medication
Take prescribed antacids at the same time as this medication - ans1) Take this medication on an empty stomach to maximize absorption The nurse should instruct the clients to take iron on an empty stomach, such as 1 hr before meals to maximize absorption. Stomach acid increases absorption. If GI adverse effects occur, the client can take with food to increase adherence to therapy even though absorption is also decreased A nurse is caring for a client prescribed HMG CoA reductase inhibitor, atorvastatin. Which of the following should be monitored while this medication is prescribed?
Liver function tests
Renal function tests
Visual acuity screening
Hearing screenings - ans1) Liver function tests Statins (HMG CoA reductase inhibitors) like atorvastatin can cause hepatotoxicity. Prior to initiating therapy the client's baseline liver function should be determined then liver function tests should be checked after 12 weeks of therapy and then every 6 months. The nurse should advise the client to observe for symptoms of liver dysfunction (anorexia, vomiting, nausea, jaundice) and to notify the provider if these occur A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medication should the nurse prepare to administer?
Flumazenil
Naloxone
Activated charcoal
Aluminum hydroxide - ans2) Naloxone The client is experiencing respiratory depression likely related to over administration of hydromorphone (Dilaudid). Naloxone (Narcan) and nalmefene (Revex) are opioid antagonsists used to reverse an overdose of opioids. A nurse is caring for a client prescribed montelukast. Which of the following should the nurse include in teaching related to this medication?
Advise client to take the medication once daily at bedtime

Bleeding time
Activated partial thromboplastin time (aPTT) - ans2) Prothrombin time (PT) This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (Move the steps of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.) *Inject air into NPH insulin vial *Withdraw short-acting insulin into syrgine *Roll NPH vial between palms of hands *Inspect vials for contaminants *Inject air into regular insulin vial Add intermediate insulin to syringe - ansInspect vials for contaminants *Roll NPH vial between palms of hands *Inject air into NPH insulin vial *Inject air into regular insulin vial *Withdraw short-acting insulin into syringe *Add intermediate insulin to syringe A nurse is preparing to administer a measles, mumps, and rubella vaccine (MMR) to an adult client. Which of the following is a contraindication to this vaccine?
The possibility of pregnancy within 4 weeks
Client allergy to strawberries
Client history of genital herpes
The possibility of overseas travel in the next month - ans1) The possibility of pregnancy within 4 weeks Pregnancy or the possibility of pregnancy with 4 weeks is a contraindication to the MMR vaccine A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
a 45 degree angle
a 60 degree angle
a 75 degree angle
a 90 degree angle - ans4) a 90 degree angle IM injections should be administered at a 90 degree angle A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? Select all that apply

*Don sterile gloves *Lubricate index finger *Use a rectal applicator for insertion *Position client supine with knees bent Insert suppository just beyond internal sphincter - ansLubricate index finger *Insert suppository just beyond internal sphincter A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - ans0.2 mL A nurse is providing care to a client with staphylococcus epidermidis, who is prescribed vancomycin. Identify the adverse effect associate with the antibiotic therapy?

Hepatotoxicity
Constipation
Infusion reaction
Immunosuppression - ans3) Infusion reaction Red Man Syndrome or an infusion reaction that results in rashes, flushing, tachycardia and hypotension can occur as an adverse reaction. For this reason, vancomycin should be administered over a 60 minute period A nurse is reviewing the medication class benzodiazepines. The nurse would use cautions when administering benzodiazepines to which of the below clients?
A client with glaucoma
A client with renal failure
A client with hypertension
A client with insomnia - ans1) A client with glaucoma Benzodiazepines can increase intraocular pressure due to the pupil-dilating effects of the medication Before administering blood products, which action should be taken?
Assess the client's temperature
Document client response
Prime IV tubing with 0.45% sodium chloride
Administer epinephrine - ans1) Assess the client's temperature Assess the client's vital signs, obtain consent for the procedure and ensure compatibility. Prime the IV tubing with 0.9% sodium chloride. The nurse would not document client response or administer epinephrine prior to starting the transfusion Disulfiram is taken by a client daily for abstinence maintenance. What is an adverse effect of this therapy?

A nurse is assessing a client who has multiple sclerosis. Which of the following assessments is the nurse's priority? - ANSAbility to swallow The greatest risk to the client is aspiration due to dysphagia. Therefore, the nurse's priority assessment is the client's ability to swallow. A nurse is assisting a client to ambulate to the bathroom when the client begins to fall. Which of the following actions should the nurse take? - ANSPlace one foot in front of the other while spreading the feet apart. The nurse should place one foot in front of the other while spreading the feet farther apart to widen their own base of support. Then the nurse should lower the client to the floor as smoothly as possible. This will assist with supporting the client's weight and help to prevent injury to the nurse. A nurse is caring for a client who has a new tracheostomy. The nurse should ensure that which of the following pieces of equipment is present in the client's room? - ANSAn obturator The nurse should ensure that a client who has a tracheostomy has an obturator at their bedside. If the tracheostomy is dislodged, an obturator is used to reinsert the outer cannula of the tracheostomy. The nurse should also ensure that a spare tracheostomy of the client's size, as well as a tracheostomy of one size smaller, supplemental humidified air or oxygen, and suction equipment are at the client's bedside to ensure safe client care. A nurse is caring for a client who is 2 days postoperative following a total knee arthroplasty. Which of the following findings indicates that the nurse should modify the client's plan of care? - ANSReports pain as a 5 on a scale of 0 to 10 A report of pain as 5 on a scale of 0 to 10 indicates the client is experiencing moderate pain. The nurse should contact the provider to obtain a prescription for pain management interventions and should update the client's plan of care. A nurse is caring for an older adult client who is postoperative following abdominal surgery. Which of the following age-related changes can result in delayed wound healing? - ANSDecreased sebum production The nurse should identify that older adult clients experience a decrease in sebum production, which causes the skin to become dry and can cause an increase in cracking. This can result in delayed wound healing.

A nurse is creating a plan of care for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan? - ANSHave the client demonstrate the use of the call light. The nurse should teach the client how to use the call light to receive assistance when there is a need to get out of bed or a chair. The nurse should keep the call light within the client's reach at all times and have the client demonstrate the ability to use it properly. A nurse is planning to discharge a client who had a stroke 1 week ago to home. The nurse should collaborate with which of the following members of the interprofessional team to assist the client with the preparation of nutritious meals? - ANSRegistered dietitian The nurse should collaborate with the registered dietitian for assistance with the preparation of nutritious meals. The registered dietitian has the specific dietary knowledge to assist both the client and those who may be assisting the client. A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to verify the client's identity? - ANSHome telephone number The nurse should recognize the client's home telephone number is an acceptable identifier to use when identifying the client prior to medication administration. Other acceptable client identifiers can be the client's medical identification number, the name on the client's wristband, or a photograph of the client. A nurse is reviewing a new prescription from a provider that reads: regular insulin 12 units before meals. Which of the following parts of the prescription should the nurse clarify with the provider? - ANSRoute of administration The nurse should identify the route of administration for the medication is missing from the prescription. All prescriptions should include the client's name, the date and time of the prescription, the name of the medication, the dose, and the frequency of administration along with the provider's name and the name of the person who is transcribing the prescription. A nurse is teaching a client who has COPD about how to use an incentive spirometer. Which of the following instructions should the nurse include? - ANS"Cough after the incentive spirometer procedure." The nurse should encourage the client to cough following the incentive spirometer procedure. After breathing deeply, secretions can become loose and coughing can help to remove them.

Peadritics alresdy graded A+, Exams of Nursing

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