Nokea
The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/73. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of:
- A. Hypotension.
- B. Prehypertension.
- C. Hypertension.
- D. Hypertension stage II.
Correct Answer: C
Rationale: BP indicates hypertension.
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The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
- A. Medications being used.
- B. Current vital signs.
- C. Potential for blood pressure to drop.
- D. Drip rate for the intravenous infusion.
- E. Time of the most recent dose of pain medication.
Correct Answer: A,B,C,D,E
Rationale: All listed information is critical for continuity of care, ensuring the receiving nurse can monitor and manage the child's condition effectively.
The nurse is caring for a 2-year-old with iron deficiency anemia. Which laboratory finding would the nurse expect to see?
- A. Elevated hemoglobin levels.
- B. Decreased mean corpuscular volume (MCV).
- C. Increased serum ferritin levels.
- D. Elevated white blood cell count.
Correct Answer: B
Rationale: Iron deficiency anemia typically shows decreased MCV, indicating microcytic red blood cells, due to reduced iron availability for hemoglobin synthesis.
The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother?
- A. Assess the child for constipation.
- B. Decrease the amount of dialysate infused for each dwell.
- C. Incorporate the increased inflow and drain times into the dialysis schedule.
- D. Monitor the child for shoulder pain during inflow and drain times.
Correct Answer: A
Rationale: Constipation can affect dialysis flow.
A child is admitted to the pediatric unit with the diagnosis of severe gastroenteritis. To prevent spread of the disease the nurse should?
- A. Institute standard precautions.
- B. Place the child in a semiprivate room.
- C. Serve meals with eating utensils that can be sterilized.
- D. Single-bag all linens.
Correct Answer: A
Rationale: Standard precautions prevent the spread of infectious gastroenteritis.
A mother of a toilet-trained 3-year-old expresses concern over her child's bedwetting while hospitalized. The nurse should tell the mother:
- A. He was too immature to be toilet trained. In a few months he should be old enough.
- B. Children are afraid in the hospital and frequently wet their bed.
- C. It's very common for children to regress when they're in the hospital.
- D. This is normal. He probably received too much fluid the night before.
Correct Answer: C
Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress.