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A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?
- A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%
- B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)
- C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002
- D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale
Correct Answer: C
Rationale: A urine specific gravity of 1.002 indicates very dilute urine
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A nurse is preparing to administer amoxicillin 350 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 7 mL
- B. 6 mL
- C. 8 mL
- D. 5 mL
Correct Answer: 7
Rationale: Formula: Volume to administer=Desired dose/Available dose ×Volume available. Calculation: 350 mg/250 mg × 5 mL=7 mL.
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Temporal
- B. Carotid
- C. Apical
- D. Dorsalis pedis
Correct Answer: C
Rationale: The apical pulse is the most reliable method for assessing heart rate in infants.
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?
- A. You should bring the infant's favorite blanket to the hospital.
- B. You should begin to manipulate the infant's bedtime based on the hospitals visiting hours.
- C. You should read the child a story about hospitalization.
- D. You will need to go home when it is not visiting hours.
Correct Answer: A
Rationale: Bringing the infant's favourite blanket can provide comfort and a sense of security in an unfamiliar hospital environment. It helps the child feel more at ease and can reduce anxiety and stress associated with hospitalization.
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Ask the child what he knows about the procedure.
- B. Allow the child to see and touch IV tubing and supplies.
- C. Describe the procedure using visual aids.
- D. Explain to the child's parents what role they will have during the procedure.
Correct Answer: A
Rationale: Understanding the child's knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety.