NCLEX Child with Cardiovascular and Hematologic Health Problems Questions
Child with Cardiovascular and Hematologic Health Problems NCLEX Practice Questions
Question 1.
The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. What should the nurse do first?
(a) Assess the vital signs.
(b) Reinforce the dressing.
(c) Apply pressure just above the catheter insertion site.
(d) Notify the health care provider (HCP).
Answer:
(c) Apply pressure just above the catheter insertion site.
Explanation:
Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the HCP CD The dressing can be reinforced after the bleeding has been contained.
Question 2.
A preschool-age child has been scheduled for a cardiac catheterization. What should the nurse do to help prepare the family for the procedure?
(a) Advise the family to bring the child to the hospital for a tour a week in advance.
(b) Explain that the child will need a large bandage after the procedure.
(c) Discourage bringing favorite toys that might become associated with pain.
(d) Explain that the child may get up as soon as the vital signs are stable.
Answer:
(b) Explain that the child will need a large bandage after the procedure.
Explanation:
The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child’s anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent’s lap.
Question 3.
When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which technique?
(a) ultra-high-frequency sound waves
(b) catheter placed in the right femoral vein
(c) cutdown procedure to place a catheter
(d) general anesthesia
Answer:
(b) catheter placed in the right femoral vein
Explanation:
In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. A cutdown procedure is rarely used. Echocardiography involves the use of ultra-high-frequency sound waves. The catheterization is usually performed under local, not general, anesthesia with sedation.
Question 4.
When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, the nurse should expect to include which information?
(a) restriction of the child’s activities for the next 3 weeks
(b) use of sponge baths until the stitches are removed
(c) use of prophylactic antibiotics before receiving any dental work
(d) maintenance of a pressure dressing until a return visit with the health care provider
Answer:
(c) use of prophylactic antibiotics before receiving any dental work
Explanation:
Prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.
Question 5.
What instructions should the nurse include in the discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin? Select all that apply.
(a) Give the medication at regular intervals.
(b) Mix the medication with a small volume of breast milk or formula.
(c) Repeat the dose one time if the child vomits immediately after administration.
(d) Notify the health care provider (HCP) of poor feeding or vomiting.
(e) Make up any missed doses as soon as realized.
(f) Notify the HCP if more than two consecutive doses are missed.
Answer:
(e) Make up any missed doses as soon as realized.
(f) Notify the HCP if more than two consecutive doses are missed.
(a) Give the medication at regular intervals.
(d) Notify the health care provider (HCP) of poor feeding or vomiting.
Explanation:
(e), (f), (a), (d) To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. The medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the medication. Taking makeup doses, or taking the medication at times other than scheduled, may adversely affect serum levels.
Question 6.
The nurse is caring for a 2-day-old neonate in the postanesthesia care unit 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which finding would alert the nurse to notify the health care provider (HCP)?
(a) oxygen saturation of 90%
(b) pale pink extremities
(c) warm, dry skin
(d) femoral pulse of 90 bpm
Answer:
(d) femoral pulse of 90 bpm
Explanation:
The normal pulse rate in a neonate is 120 to 160 bpm. Therefore, a femoral pulse rate of 90 bpm is too low. Diminished peripheral pulses, coolness and mottling of the extremities, delayed capillary refill, hypotension, and decreased urine output are indicative of low cardiac output and poor perfusion. The neonate may be experiencing a complication of the surgery, such as blood loss or leaking of fluid into the interstitial space. The surgeon should be notified immediately to correct the diminished pulse, through either medications or transfusions.
An oxygen saturation between 85% and 100% is considered normal. The surgeon does not need to be notified unless the oxygen saturation falls below 85%. Pale pink extremities are considered a normal finding. If mottling or cyanosis develops, the surgeon should be notified immediately. Warm, dry skin is also a normal finding. If the skin becomes cool or appears cyanotic, the surgeon should be notified.
Question 7.
Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select all that apply.
(a) murmur
(b) history of squatting
(c) bounding pulses
(d) cyanosis
(e) faint pulse
(f) tachypnea
Answer:
(a) murmur
(b) history of squatting
(d) cyanosis
(f) tachypnea
Explanation:
(a), (b), (d), (f) TOF is a heart condition with four defects: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. A systolic murmur, cyanosis, and tachypnea are all symptoms of TOF. Toddlers with uncorrected defects instinctively squat [knee-chest position) to decrease the return of systemic venous blood to the heart. Coarctation of the aorta is a narrowing in the descending aorta, obstructing the systemic blood outflow. Infants with severe constriction may present with faint puise in lower extremities and bounding pulses in upper extremities.
Question 8.
The nurse is caring for a newborn with a large ventricular septal defect. The client has undergone pulmonary artery banding. Which assessment finding best indicates that the pulmonary artery band is functioning effectively?
(a) Capillary refill is < 3 seconds.
(b) Urine output is >1 mL/kg/h.
(c) Breath sounds are clear and equal bilaterally.
(d) Radial pulses are bounding.
Answer:
(c) Breath sounds are clear and equal bilaterally.
Explanation:
Pulmonary artery banding is a palliative treatment used in pediatric clients with congenital cardiac defects with increased pulmonary blood flow. The pulmonary artery band reduces excessive pulmonary blood flow and protects the lungs from irreversible damage. When the pulmonary artery band is functioning properly, the lungs should no longer be receiving an increased amount of blood flow, which would be reflected in clear and equal breath sounds. A capillary refill of < 3 seconds and a urine output > 1 mL/kg/h reflect adequate peripheral perfusion. Bounding radial pulses suggest increased pulmonary blood flow.
Question 9.
A child diagnosed with tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do first?
(a) Obtain a prescription for sedation for the child.
(b) Assess for an irregular heart rate and rhythm.
(c) Explain to the child that it will only hurt for a short time.
(d) Place the child in a knee-to-chest position.
Answer:
(d) Place the child in a knee-to-chest position.
Explanation:
The child is experiencing TET or hypoxic episode. Therefore, the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced.
Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.
Question 10.
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principles should the nurse address first?
(a) organizing information to be taught in a logical sequence
(b) arranging to use actual equipment for demonstrations
(c) building the teaching on the child’s current level of knowledge
(d) presenting the information in order from simplest to most complex
Answer:
(c) building the teaching on the child’s current level of knowledge
Explanation:
Before developing any teaching program for a child, the nurse’s first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child’s interest will soon be lost if familiar material is repeated too often.
The nurse can then organize the information in a sequence because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided based on the child’s current knowledge and response to teaching.
Question 11.
The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output?
(a) bounding pulses and mottled skin
(b) altered level of consciousness and thready pulse
(c) capillary refill of 2 seconds and blood pressure of 96/67 mm Hg
(d) extremities warm to the touch and pale skin
Answer:
(b) altered level of consciousness and thready pulse
Explanation:
With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease in level of consciousness.
Question 12.
Which intervention is the highest priority for the therapeutic management of a child with congestive heart failure (CHF) caused by pulmonary stenosis?
(a) educating the family about the signs and symptoms of infection
(b) administering enoxaparin to improve left ventricular contractility
(c) assessing heart rate and blood pressure every 2 hours
(d) administrating furosemide to decrease systemic venous congestion
Answer:
(d) administrating furosemide to decrease systemic venous congestion
Explanation:
Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Furosemide is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF, but treating the client’s CHF is the priority.
Enoxaparin is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF, but assessments do not treat the problem.
Question 13.
An infant weighing 9 kg is in the pediatric intensive care unit following arterial switch surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take?
(a) Notify the health care provider [HCP] immediately.
(b) Record the urine output in the medical record.
(c) Administer a fluid bolus immediately.
(d) Assess for other signs of hypervolemia.
Answer:
(b) Record the urine output in the medical record.
Explanation:
Urine output for an infant weighing 9 kg should be 1 mL/kg/h. Sixteen milliliters of urine output is more than adequate for 1 hour, so the nurse should record the output in the medical record There is no reason to notify the HCP Q regarding adequate urine output. The infant has adequate output, so there is no need for a fluid bolus. A fluid bolus could also cause the infant to become fluid overloaded, increasing the workload on the heart. There is no information in the question indicating that the child is hypervolemic.
Question 14.
A child has had open heart surgery to repair a tetralogy of Fallot with a patch. Which instructions should the nurse give to the parents?
(a) Notify all health care providers (HCP) before invasive procedures for the next 6 months.
(b) Maintain adequate hydration of at least 10 glasses of water a day.
(c) Provide for frequent rest periods and naps during the first 4 weeks.
(d) Restrict the ingestion of bananas and citrus fruit.
Answer:
(a) Notify all health care providers (HCP) before invasive procedures for the next 6 months.
Explanation:
Children who have undergone open heart surgery with a patch are at risk for infection, especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The newest evidence-based guidelines suggest that once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify providers before invasive procedures so antibiotics can be prescribed for that time period.
Having the child drink a very large amount of water may lead to fluid overload. Children gear their rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated serum potassium requiring restriction.
Question 15.
After undergoing a tetralogy of Fallot repair, a preschool child is transferred to the pediatric floor. Which intervention does the nurse tells the family to expect?
(a) a reduced sodium diet
(b) an activity restriction for several days
(c) assignment to an isolation room
(d) limiting visitation to parents only
Answer:
(a) a reduced sodium diet
Explanation:
Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child’s sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate.
Typically, the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client; therefore, isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.
Question 16.
After surgery to correct a tetralogy of Fallot, the child’s parents express concern to the nurse that their 4-year-old child wants to be held more frequently than usual. What does the nurse recommend?
(a) introducing a new skill
(b) beginning play therapy
(c) encouraging the behavior
(d) having the volunteer hold the child
Answer:
(b) beginning play therapy
Explanation:
The child is exhibiting regression. During periods of stress, children frequently revert to behaviors that were comforting in earlier developmental stages; play therapy is one way to help the child cope with the stress. Teaching a new skill most likely would add more stress.
Parents should be instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to them through encouragement or discouragement. Having someone else hold the child does not encourage coping with the stress or promoting appropriate development.
Question 17.
The parent of a child hospitalized with tetralogy of Fallot tells the nurse that the child’s 3-year-old sibling has become quiet and shy and demonstrates more than a usual amount of genital curiosity since this child’s hospitalization. What should the nurse tell the parent?
(a) “This behavior is very typical for a 3-year-old.”
(b) “This may be how your child expresses feeling a need for attention.”
(c) “This may be an indication that your child may have been sexually abused.”
(d) “This may be a sign of depression in your child.”
Answer:
(b) “This may be how your child expresses feeling a need for attention.”
Explanation:
According to Erikson, the central psychosocial task of a preschooler is to develop a sense of initiative versus guilt. Any environmental situation may affect the child. In this situation, the sibling is probably feeling less attention from the mother and trying to resolve the conflict in an inappropriate way. Three-year-olds are usually active and outgoing. These behaviors represent a change. Data are not sufficient to suggest the child has been exposed to a sexual experience. Symptoms of depression would include withdrawal and fatigue.
Question 18.
An adolescent client is admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first.
(a) Report the heart rate to the health care provider (HCP).
(b) Apply lotion to the rash.
(c) Splint the joints to relieve the pain.
(d) Request a prescription to treat the elevated temperature.
Answer:
(a) Report the heart rate to the health care provider (HCP).
Explanation:
The child’s heart rate of 150 bpm is significantly above its rate at the time of his admission. The nurse must notify the HCP. The increase in heart rate may indicate carditis, a possible complication of rheumatic fever that can cause serious and lifelong effects on the heart. The HCP will intervene with medication and cardiac monitoring. While lotion may provide comfort, the most important action for the nurse is to notify the HCP of the increased heart rate. Splinting will not help the inflammation that is causing the painful joints. The joint pain will migrate and subside with time. The temperature is not elevated at this time and does not require intervention.
Question 19.
The nurse plans the care for a child with rheumatic fever in the acute phase. What is the most important action for the nurse to teach the parents to monitor the child’s progress?
(a) listening to bilateral breath sounds
(b) monitoring the child’s pulse
(c) observing closely for abnormal movements
(d) recording the child’s input and output
Answer:
(b) monitoring the child’s pulse
Explanation:
Tachycardia is associated with inflammation of the heart in rheumatic fever. Improvements in pulse rate are an indication that inflammation is decreasing. The nurse should teach the parents to monitor the child’s pulse. Preferably the pulse is taken apically for a full minute. The pulse may be prescribed during sleep and wake times to determine activity tolerance. It is unnecessary to teach parents to monitor breath sounds or intake and output. The parents should report if the child develops purposeless movements, but presence or absence chorea is not the primary indicator of how rheumatic fever is progressing.
Question 20.
The nurse discusses the treatment plan for an adolescent with rheumatic fever with the family. Which parent statement indicates the need for additional teaching about the therapeutic management of rheumatic fever?
(a) “Antibiotics will be prescribed for at least 5 years to prevent disease reoccurrence.”
(b) “Anticonvulsants will be needed for a lifetime if our child develops involuntary movements.”
(c) “Corticosteroids may be prescribed if nonsteroidal anti-inflammatory medicines are not effective.”
(d) “Diuretics may be needed if our child develops congestive heart failure.”
Answer:
(b) “Anticonvulsants will be needed for a lifetime if our child develops involuntary movements.”
Explanation:
Phenobarbital or diazepam may be needed to treat involuntary movements, but there are typically no residual effects from chorea that require lifetime treatment. Clients who have a second episode of rheumatic fever are at extreme risk of heart valve damage. Clients must stay on prophylactic antibiotics for at least 5 years or until adulthood. Nonsteroidal anti-inflammatory (NSAID) medications like ibuprofen are used as first-line treatments for inflammation and joint pain, but corticosteroids may be needed if the child is not responding to NSAIDS. Children with rheumatic fever may need digitalis and diuretics if heart failure develops.
Question 21.
A school-age client with rheumatic fever is on long-term aspirin therapy. Which client statement most indicates that the client is experiencing a serious adverse reaction to aspirin?
(a) “I hear ringing in my ears.”
(b) “I put lotion on my itchy skin.”
(c) “My stomach hurts after I take that medicine.”
(d) “These pills make me cough.”
Answer:
(a) “I hear ringing in my ears.”
Explanation:
Tinnitus is an adverse effect of prolonged aspirin therapy, and the child should be examined by a health care provider (HCP) Q for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever, and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.
Question 22.
A school-age child has been put on an activity restriction during the acute phase of rheumatic fever. Which outcome indicates that the activity restriction has been effective?
(a) The joints are free from permanent injury.
(b) The resting heart rate is between 60 and 100 bpm.
(c) The child exhibits a decrease in chorea movements.
(d) The subcutaneous nodules over the joints are no longer palpable.
Answer:
(b) The resting heart rate is between 60 and 100 bpm.
Explanation:
During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to reduce the work of the heart. Bed rest with limited activity is necessary to prevent heart failure. Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs with rheumatic fever.
The chorea movements associated with rheumatic fever are self-limited and usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not appropriate for evaluating the effectiveness of activity restrictions.
Question 23.
Which initial physical finding indicates the development of carditis in a child with rheumatic fever?
(a) heart murmur
(b) low blood pressure
(c) irregular pulse
(d) anterior chest wall pain
Answer:
(a) heart murmur
Explanation:
In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis. The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement, and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular.
Question 24.
The health care provider (HCP) prescribes pulse assessments through the night for a school-age child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by which factor?
(a) the morning digitalis dose
(b) routine activity during waking hours
(c) a warmer daytime environment
(d) normal variations in day and evening hours
Answer:
(b) routine activity during waking hours
Answer:
An above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.
Question 25.
Which action should the nurse perform to help alleviate a child’s joint pain associated with rheumatic fever?
(a) Maintain the joints in an extended position.
(b) Apply gentle traction to the child’s affected joints.
(c) Support proper alignment with rolled pillows.
(d) Use a bed cradle to keep linens off joints.
Answer:
(d) Use a bed cradle to keep linens off joints.
Explanation:
For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional.
Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, which are not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client’s position are recommended, but these measures are not likely to relieve pain.
Question 26.
When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease (KD), which intervention should be the priority?
(a) taking vital signs every 6 hours
(b) monitoring intake and output every hour
(c) minimizing skin discomfort
(d) providing passive range-of-motion exercises
Answer:
(b) monitoring intake and output every hour
Explanation:
Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF. which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it does not take priority over monitoring the child’s hourly intake and output. Passive range-of-motion exercises would be done if the child develops arthritis
Question 27.
A school-age child has been diagnosed with Kawasaki disease. What teaching should the nurse provide the family about the pharmacologic management of Kawasaki disease?
(a) Inactivated vaccines are permissible while receiving IV immunoglobulin for Kawasaki disease.
(b) The benefits of taking aspirin for Kawasaki disease outweigh the risk of Reye syndrome.
(c) Corticosteroids are often needed to control inflammation in Kawasaki disease.
(d) Platelet infusions are needed with Kawasaki disease to prevent internal bleeding.
Answer:
(b) The benefits of taking aspirin for Kawasaki disease outweigh the risk of Reye syndrome.
Explanation:
Vasculitis in Kawasaki disease can lead to life-threatening complications such as myocardial infarction and aneurysms. High doses of aspirin or NSAIDS are frequently prescribed to control fever, inflammation, and platelet aggregation. While Reye Syndrome has been associated with the use of aspirin in children with viral infections, the same risk has not been found with aspirin use and Kawasaki disease.
IV immunoglobulin provides a passive immunity that reduces the ability of a client to develop active immunity from vaccination. Therefore, routine vaccination should be delayed. Corticosteroids are contraindicated with Kawasaki disease as they have been associated with aneurysm formation. Platelet infusions are not part of Kawasaki treatment as medications are needed to reduce platelet aggregation.
Question 28.
A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first?
(a) Apply lotion to the hands and feet.
(b) Offer foods the toddler likes.
(c) Engage the child in quiet activities.
(d) Encourage the parents to get some rest.
Answer:
(c) Engage the child in quiet activities.
Explanation:
One of the characteristics of children with KD is irritability. They are often inconsolable. Engaging the child in quiet activities help calm the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child’s irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.
Question 29.
Which information should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) following treatment with intravenous immunoglobulin (IVIG)?
(a) Offer the child extra fluids every 2 hours for 2 weeks.
(b) Take the child’s temperature daily for several days.
(c) Check the child’s blood pressure daily until the follow-up appointment.
(d) Call the health care provider (HCP) if the irritability lasts for 2 more weeks.
Answer:
(b) Take the child’s temperature daily for several days.
Explanation:
The child’s temperature should be taken daily for several days after discharge because children who develop a fever may require a second IVIG treatment. Offering the child fluids every 2 hours is not necessary. Doing so increases the child’s risk for CHF.
Checking the child’s blood pressure at home usually is not included as part of the discharge instructions because by the time of discharge the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.
Question 30.
The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis?
(a) Exercise in cool temperatures.
(b) Drink at least 2 quarts of fluids per day.
(c) Avoid contact sports.
(d) Take anti-inflammatory medications before exercising.
Answer:
(b) Drink at least 2 quarts of fluids per day.
Explanation:
Increasing fluid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell disease should avoid exercising in cool temperatures or swimming in cold water. While contact sports are not recommended because of bleeding risks, they do not cause sickle crisis. Taking an anti-inflammatory medication before exercising does not prevent sickle cell crisis.
Question 31.
The nurse admits a 1-year-old child to the hospital with the diagnosis of sickle cell crisis. The nurse explains to the parents that which condition leads to local tissue damage during a sickle cell crisis?
(a) autoimmune reaction complicated by hypoxia
(b) lack of oxygen in the red blood cells
(c) obstruction to circulation
(d) elevated serum bilirubin concentration
Answer:
(c) obstruction to circulation
Explanation:
Characteristic sickle cells tend to cause “log jams” in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells. The erythrocytes are sickle shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
Question 32.
The parents of a child with sickle cell disease ask the nurse why their child’s hemoglobin was normal at birth but now the child has S hemoglobin. Which response by the nurse is appropriate?
(a) “The placenta prevents the passage of the hemoglobin S from the mother to the fetus.”
(b) “The red bone marrow does not begin to produce hemoglobin S until several months after birth.”
(c) “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity. ”
(d) “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.”
Answer:
(d) “The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth.”
Explanation:
Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn’s hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin.
The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.
Question 33.
At a wellness check, the nurse monitors the routine laboratory values of an asymptomatic school-age client with sickle cell anemia. The reports reveal that the child has a hemoglobin of 10 g/100 mL (100 g/1 L). The nurse plans the client’s care based on which interpretation of the hemoglo-bin level?
(a) The child will most likely need a blood transfusion for the low hemoglobin.
(b) This hemoglobin level is a typical finding in children with this disease.
(c) The folic acid dose may need to be increased to improve hemoglobin production.
(d) Additional tests are needed to determine if a sequestration crisis is causing the low hemoglobin.
Answer:
(b) This hemoglobin level is a typical finding in children with this disease.
Explanation:
Between crises, hemoglobin levels between 6 and 9 g/100 mL (60 to 90/L) are typical for children with sickle cell anemia. The decision to transfuse a child must be weighed against the risks. Transfusions are most often considered to treat life-threatening sickle cell complications, to keep HbS levels within a desired range, or as prophylaxis before surgery.
Oral folic acid is frequently prescribed to rebuild hemolyzed RBCs. It would be appropriate for the nurse to verify that the client was taking folic acid as prescribed before making any further interpretations. Clients with sequestration crisis present with symptoms including pain and signs and symptoms of hypovolemia.
Question 34.
Which action indicates that the parents of a 12-month-old with iron-deficiency anemia under¬stand how to administer iron supplements? Select all that apply.
(a) administering iron supplements in combination with fruit juice
(b) scheduling iron supplements with meals
(c) verbalizing the need to report dark stools
(d) brushing the child’s teeth after administering the iron supplements
(e) decreasing the dietary intake of foods fortified with iron
Answer:
(d) brushing the child’s teeth after administering the iron supplements
Explanation:
Parent teaching concerning a child with iron-deficiency anemia should include directions about giving iron combined with fruit juice, in divided doses, between meals, and with a drop¬per for a 12-month-old or through a straw for older toddlers. Iron stains teeth, so brushing the teeth and administering liquid iron through a dropper or straw are necessary to prevent staining the teeth.
Iron should not be given with milk, antacids, or tea and should be administered on an empty stomach. Iron will cause the stool to become black or green, which is normal and does not need to be reported. However, light-colored stools indicate the iron is not being absorbed and should be reported.
Question 35.
During a health history the nurse learns that a pediatric client seldom eats foods high in iron. Which physical assessment findings would suggest that the child has developed iron-deficiency anemia? Select all that apply.
(a) decreased heart rate
(b) pale skin
(c) swollen tongue
(d) systolic murmur
(c) yellowed sclera
Answer:
(b) pale skin
(c) swollen tongue
(d) systolic murmur
Explanation:
(b), (c), (d) Pale skin is one of the most common physical findings associated with iron-deficiency anemia. Lower levels of myoglobin lead to soreness and swelling of the tongue. Low levels of hemoglobin force the heart to work harder to pump blood. Tachycardia and systolic murmurs may result. Anemia presents as an elevated heart rate not decreased. Yellowed sclera is consistent with hemolytic anemia.
Question 36.
Which statement by the parent of a toddler most suggests that the child is at risk for iron-deficiency anemia?
(a) “He drinks over four glasses of milk per day.”
(b) “He must drink over 10 oz (300 mL) of apple juice per day.”
(c) “He refuses to eat more than two different kinds of vegetables.”
(d) “He does not like meat, but he will eat small amounts of it.”
Answer:
(a) “He drinks over four glasses of milk per day.”
Explanation:
Milk is a poor source of iron. Toddlers should have between two and three servings of milk per day. Iron-deficiency anemia can be caused when excessive milk intake of more than 32oz (1 L)/day intake displaces iron-rich food in the diet. While 6oz (300 mL) is the recommended daily limit for apple juice, it does contain more iron than milk. Food preferences vary among children. It is accept¬able for the child to refuse foods as long as the diet is balanced and contains adequate calories.
Question 37.
Which foods should the nurse encourage a parent to offer to a child with iron-deficiency anemia?
(a) cereal, milk, and yellow vegetables
(b) potato, peas, and chicken
(c) macaroni, cheese, and ham
(d) pudding, green vegetables, and rice
Answer:
(b) potato, peas, and chicken
Explanation:
Potatoes, peas, chicken, green vegetables, and fortified cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While pudding (made with fortified milk) and green vegetables contain some iron, the better diet has protein and iron from the chicken and potato.
Question 38.
What is the most appropriate method to use when drawing blood from a child with hemophilia?
(a) Use finger punctures for lab draws.
(b) Prepare to administer platelets.
(c) Apply heat to the extremity before venipunctures.
(d) Schedule all labs to be drawn at one time.
Answer:
(d) Schedule all labs to be drawn at one time.
Explanation:
Coordinating labs to minimize sticks reduces trauma and the risk of bleeding. Fingersticks in general are more painful and associated with more bleeding than are venipunctures. In hemophilia, platelets are typically normal. Heat would increase vasodilatation and increase bleeding.
Question 39.
A diagnosis of hemophilia A is confirmed in an infant. Which instruction should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
(a) Administer one-half of a children’s aspirin for a temperature higher than 101°F (38.3°C).
(b) Sew thick padding into the elbows and knees of the child’s clothing.
(c) Check the color of the child’s urine every day.
(d) Expect the eruption of the primary teeth to produce moderate to severe bleeding.
Answer:
(b) Sew thick padding into the elbows and knees of the child’s clothing.
Explanation:
As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant’s risk for bleeding. Because genitourinary bleeding is not a typical problem
in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.
Question 40.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and implements which intervention?
(a) administers an aspirin-containing compound
(b) institutes rest, ice, compression, and elevation
(c) begins physical therapy with active range of motion
(d) initiates skin traction immobilization
Answer:
(b) institutes rest, ice, compression, and elevation
Explanation:
The child is displaying symptoms of bleeding in the joint, and factor replacement is indicated. The RICE method is used as a supportive measure to help control the bleeding. Aspirin- containing compounds contribute to bleeding and should never be used to control pain. Physical therapy is instituted after acute bleeding to prevent further damage. Orthopedic traction is considered in some rare cases during the rehabilitation phase, but not the acute phase.
Question 41.
The nurse creates a teaching plan for the family of a child with hemophilia who receives recombinant antihemophilic factor. Which problem is most important for the nurse to teach the family to report immediately?
(a) yellowing of the skin
(b) constipation
(c) abdominal distention
(d) hives
Answer:
(d) hives
Explanation:
Administration of antihemolytic factor (recombinant) is a biosynthetic preparation of factor VIII that carries the risk of severe allergic reaction. Signs include hives, difficulty breathing, tachycardia, chills, and fever. Originally, factor VIII preparations were derived from large pools of human plasma and carried the risk of hepatitis, but recombinant preparations do not. Antihemolytic factor (recombinant) is not associated with constipation or abdominal distention.
Question 42.
The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which activity should the nurse suggest as ideal?
(a) snow skiing
(b) swimming
(c) basketball
(d) gymnastics
Answer:
(b) swimming
Explanation:
Swimming is an ideal activity for a child with hemophilia because it is a noncontact sport. Many noncontact sports and physical activities that do not place excessive strain on joints are also appropriate. Such activities strengthen the muscles surrounding joints and help control bleeding in these areas.
Noncontact sports also enhance general mental and physical well-being. Falls and subsequent injury to the child may occur with snow skiing. Basketball is a contact sport and therefore increases the child’s risk for injury. Gymnastics is a very strenuous sport. Gymnasts frequently have muscle and joint injuries that result in bleeding episodes.
Question 43.
An adolescent client is admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which signs and symptoms require the most urgent nursing intervention?
(a) fatigue and anorexia
(b) fever and petechiae
(c) swollen neck lymph glands and lethargy
(d) enlarged liver and spleen
Answer:
(b) fever and petechiae
Explanation:
Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other infections and bleeding. The nurse should initiate infection control and safety precautions to reduce these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression.
Although the client should be told about the need for rest and meal planning, such teaching is not the priority intervention. Swollen glands and lethargy may be uncomfortable, but they do not require immediate intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the abdomen; however, these precautions are not the priority.
Question 44.
A school-age client with leukemia is receiving cyclophosphamide. The nurse should assess the client for which adverse effect of cyclophosphamide?
(a) photosensitivity
(b) ataxia
(c) cystitis
(d) cardiac arrhythmias
Answer:
(c) cystitis
Explanation:
Cystitis is a potential adverse effect of cyclophosphamide. The client should be monitored for pain on urination. Photosensitivity, ataxia, and cardiac arrhythmias are not adverse effects associated with cyclophosphamide.
Question 45.
After the nurse teaches the parent of a child newly diagnosed with leukemia about the disease, which description if given by the parent best indicates understanding the nature of leukemia?
(a) “Leukemia is an infection resulting in increased white blood cell production.”
(b) “Leukemia is a type of cancer characterized by an increase in immature white blood cells.”
(c) “Leukemia is an inflammation associated with enlargement of the lymph nodes.”
(d) “Leukemia is an allergic disorder involving increased circulating antibodies in the blood.”
Answer:
(b) “Leukemia is a type of cancer characterized by an increase in immature white blood cells.”
Explanation:
Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is characterized by a proliferation of immature white blood cells. Leukemia is not an infection, inflammation, or allergic disorder.
Question 46.
The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client?
|
Test |
Traditional Units |
SI Units |
|
WBC |
6,500 mm3 |
6.5 × 109/L |
|
Platelet count |
40, 000 mm3 |
40 × 109/L |
|
HCT |
41.2% |
0.412 |
(a) activity intolerance
(b) risk of bleeding
(c) impaired tissue perfusion
(d) risk for infection
Answer:
(b) risk of bleeding
Explanation:
A normal platelet count is 150,000 to 400.0 pL (150 to 400 x 10fl/L). A platelet count of 40.0 pL (40 x 109/L) is low and puts the child at risk for injury, bruising, and bleeding. Hematocrit of 41.2% (0.41) is normal; therefore, the child will have adequate oxygenation and tissue perfusion. The white blood cell count of 6,500 mm3 (6.5 x 109/L) is normal; therefore, the child has no increase in risk for infection.
Question 47.
The nurse teaches the family of child with leukemia about preventing infections. How should the nurse explain to the parents why their child is at risk for infections?
(a) “Abnormal platelets lead to bruising and bleeding.”
(b) “There are an insufficient number of circulating white blood cells.”
(c) “The number of red blood cells is inadequate for carrying oxygen.”
(d) “Immature white blood cells are incapable of handling an infectious process.”
Answer:
(d) “Immature white blood cells are incapable of handling an infectious process.”
Explanation:
In leukemia, although there is an increased number of immature white blood cells, they are unable to combat infection. Lack of mature white blood cells puts a child with leukemia at risk for infection. The major morbidity and mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia. Decreased red blood cells are not directly caused by infection. While platelets play a role in the body’s response to infection, bleeding does not directly cause infections.
Question 48.
Which beverage should the nurse plan to give a child with leukemia to relieve nausea?
(a) orange juice
(b) weak tea
(c) plain water
(d) carbonated soda
Answer:
(d) carbonated soda
Explanation:
Carbonated beverages ordinarily are best tolerated when a child feels nauseated. Many children find cola drinks especially easy to tolerate, but noncola beverages are also recommended. Orange juice usually is not tolerated well because of its high acid content. Tea may also be too acidic, and many children do not like tea. Water does not relieve nausea.
Question 49.
Which medication prescription to help relieve pain in a child with leukemia should the nurse question?
(a) hydromorphone
(b) acetaminophen with codeine
(c) ibuprofen
(d) hydrocodone
Answer:
(c) ibuprofen
Explanation:
Ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia. Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen, may be prescribed to control pain and may be used in combination with codeine or hydrocodone if pain is more severe. Hydromorphone may also be used for severe pain.
Question 50.
After teaching a child with leukemia about a scheduled bone marrow aspiration, the nurse determines that the teaching has been successful when the child identifies which place as the site for the aspiration?
(a) right lateral side of the right wrist
(b) middle of the chest
(c) distal end of the thigh
(d) back of the hipbone
Answer:
(d) back of the hipbone
Explanation:
Although bone marrow specimens may be obtained from various sites, the most commonly used site in children is the posterior iliac crest, the back of the hipbone. This area is close to the body’s surface but removed from vital organs. The area is large, so specimens can easily be obtained. For infants, the proximal tibia and the posterior iliac crest are used. The middle of the chest or sternum is the usual site for bone marrow aspiration in an adult. The wrist, chest, and thigh are not sites from which to obtain bone marrow specimens.
Question 51.
The nurse and parents plan for the discharge of a child with leukemia who is receiving dactino-mycin and vincristine. Which intervention should the nurse include in the teaching plan?
(a) Encourage increased fluid intake.
(b) Keep the child out of the sun.
(c) Monitor the child's heart rate.
(d) Observe the child for memory loss.
Answer:
(a) Encourage increased fluid intake.
Explanation:
Dactinomycin and vincristine both cause nausea and vomiting. Oral fluids are encouraged, and antiemetics are given to prevent dehydration. Avoiding sun exposure is not necessary because photosensitivity is not associated with these drugs. Heart rate changes and memory issues also are not associated with either of these two drugs.
Question 52.
After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child’s death is imminent. Which statement offers the nurse the best guide in making plans to assist the parents in dealing with their child’s imminent death?
(a) Knowing that the prognosis is poor helps prepare parents for the death of children.
(b) Parents are especially grieved when a child does well at first but then declines rapidly.
(c) Parents’ trust in health care personnel is most often destroyed by a death that is considered untimely.
(d) It is more difficult for parents to accept the death of an older child than that of a toddler.
Answer:
(b) Parents are especially grieved when a child does well at first but then declines rapidly.
Explanation:
It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child’s death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more difficult for parents to accept the death of an older child than that of a younger child.
Question 53.
A school-age child with leukemia will be taking vincristine. The nurse should encourage the child to eat what kind of diet?
(a) high-residue
(b) low-residue
(c) low-fat
(d) high-calorie
Answer:
(a) high-residue
Explanation:
Vincristine may cause constipation, so the client should be encouraged to eat a high- residue (fiber) diet. The other diets do not help with constipation that can occur while receiving vincristine.
Question 54.
A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan?
(a) Monitor the child’s temperature at school.
(b) Avoid any live attenuated vaccines.
(c) Take daily vitamin and mineral supplements.
(d) Stay away from other children.
Answer:
(b) Avoid any live attenuated vaccines.
Explanation:
Children who are immunosuppressed should not receive any live attenuated vaccines. Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps, rubella, and oral polio vaccine can develop severe forms of the diseases for which they are being immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies, and it is recommended that immunizations be delayed for 3 months after the immunosuppressive drugs have been discontinued.
It is unnecessary to monitor the child’s temperature at school unless the child shows symptoms of an illness. Vitamin and mineral supplements are not normally given in conjunction with immunosuppressive drugs. When the client is immunosuppressed, the client should avoid only persons who have an infection.
Question 55.
A nurse is proving anticipatory guidance to the family of a school-age child with acute lymphocytic leukemia. Which recommendation should the nurse make?
(a) home schooling for 2 years
(b) avoiding all athletic activities
(c) encouraging trips to the shopping mall
(d) being treated as “normal” as much as possible
Answer:
(d) being treated as “normal” as much as possible
Explanation:
Any child with a chronic illness should be treated as normally as possible. Unless the child has severe bone marrow depression, he or she should be allowed to go to school with others and can go to the mall. If the child is in remission, athletic activities are allowed.
Question 56.
Which signs and symptoms of leukemia would lead the nurse to suspect the client has thrombocytopenia? Select all that apply.
(a) fever
(b) petechiae
(c) epistaxis
(d) anorexia
(e) bone pain
(f) dyspnea
Answer:
(b) petechiae
(c) epistaxis
Explanation:
(b), (c) Children with acute lymphocytic leukemia have a reduced platelet count (thrombocytopenia), reduced red blood cell count (anemia), and reduced white blood cell count (neutropenia) because of unrestricted proliferation of immature white blood cell. Chemotherapy is used to treat leukemia and contributes to thrombocytopenia, neutropenia, and anemia.
Clients with thrombocytopenia are at risk for bleeding. Petechiae (small red or purple spots on the skin) and epistaxis (nose bleeds) are both signs of bleeding. A fever is a result of a decreased white blood cell count. Anorexia and dyspnea (shortness of breath) are a result of a decreased red blood cell count. Bone pain is a result of stress on the bone related to the unrestricted proliferation of the leukemic blast cells.
Question 57.
A transfusion of packed red blood cells has been prescribed for a 1-year-old with sickle cell anemia. The infant has a 25-gauge IV infusing dextrose with sodium and potassium. Using the situation, background, assessment, and recommendation (SBAR) method of communication, the nurse contacts the health care provider (HCP) and makes which recommendation?
(a) starting a second IV with a 22-gauge catheter to infuse normal saline with the blood
(b) using the existing IV, but changing the fluids to normal saline for the transfusion
(c) replacing the IV with a 22-gauge catheter to infuse the prescribed fluids
(d) starting a second IV with a 25-gauge catheter to infuse normal saline with the transfusion
Answer:
(b) using the existing IV, but changing the fluids to normal saline for the transfusion
Explanation:
The best evidence indicates that a catheter as small as 27 gauge may safely be used for transfusion in children, but blood must be infused with normal saline, not dextrose. A 1-year-old should be able to maintain his or her blood glucose for the 2-hour duration of the infusion without the need for a second IV.
Question 58.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical/vocational nurse (LPN/VN)? Select all that apply.
(a) administering oral medications
(b) administering IV push morphine
(c) obtaining vital signs
(d) providing morning hygiene
(e) obtaining circulation checks
(f) providing discharge teaching
Answer:
(a) administering oral medications
(c) obtaining vital signs
(d) providing morning hygiene
Explanation:
(a), (c), (d) The RN’s scope of practice includes assessment, planning, implementing, and evaluation. Only aspects of care implementation may be delegated to the LPN/VN and the exact skills that may be delegated vary by state and institution. In general, LPN/VNs have been trained to perform the tasks of administering oral medications, performing hygiene, and recording the intake and output.
LPN/VNs may also take vital signs to gather data, but the nurse must interpret the data. Administering IV morphine requires assessment of the client’s respiratory status before, during, and after the procedure. Circulation checks are assessments the RN should complete.
Question 59.
The nurse assists with conscious sedation of a school-age client undergoing a bone marrow biopsy. What is the nurse’s most important responsi¬bility during the procedure?
(a) administering the topical anesthetic
(b) keeping the parents informed
(c) monitoring the client
(d) recording the procedure
Answer:
(c) monitoring the client
Explanation:
During conscious sedation, the client may lose protective reflexes, and adequate respiratory and cardiac function may be impaired. At every procedure, there must be one health care professional whose sole responsibility is to monitor the client. Topical agents must be given in advance of the procedure to be effective. During the procedure, the nurse would not leave the child to speak with the parents. While the procedure would be documented according to the facility’s protocols, proper monitoring of the client is the intervention most associated with reducing risks.
Question 60.
The nurse transfers a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child’s blood pressure has been fluctuating but has been stable during the last 2 hours. What information should the nurse include in the handoff report? Select all that apply.
(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
(f) medications given during surgery
Answer:
(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
Explanation:
(a), (b), (c), (d), (e) The report made when nurses are “handing off” a client from one nursing unit to another must include information about the condition of the client, potential for changes in the client’s condition, current medications, and care and services received. It is not necessary to know what medications were given in surgery to provide safe care at this point.
Question 61.
The nurse prepares to administer furosemide to a preschooler with a heart defect. The nurse verifies the child’s identity by checking the arm band and using which method?
(a) asking the child to state her name
(b) checking the room number
(c) asking the child to tell her birth date
(d) asking the parent the child’s name
Answer:
(d) asking the parent the child’s name
Explanation:
Safety standards require the use of two identifiers prior to medication administration. A parent can be used as the second identifier. Many young children will only answer to a nickname that does not coincide with the medical identification band or may answer to any name. It is common for children on a pediatric floor to go into each other’s rooms. Small children may not know their birth date.
Question 62.
A school-age client with hemophilia A has fallen and badly bruised his knee. Which action should the nurse do first to manage the client’s hemarthrosis?
(a) Use active range of motion to prevent immobility.
(b) Apply cold packs to promote vasoconstriction.
(c) Apply pressure and immobilize the joint.
(d) Notify the health care provider (HCP) of the injury.
Answer:
(c) Apply pressure and immobilize the joint.
Explanation:
Application of pressure and immobilization of the affected limb are the first priority. Pressure is required to stop the bleeding, and immobilization aids in reducing swelling and pain. Active range of motion is recommended after the bleeding is controlled. The application of cold packs can be helpful in diminishing swelling and pain. Cold packs will also promote vasoconstriction, which can help reduce the bleeding. The health care provider (HCP) should be informed of the bleeding episode after initial measures to control the bleeding are implemented.
Question 63.
The nurse completes discharge teaching with the family of an 8-week-old infant with congenital heart disease. What is the most important informa¬tion for the nurse to convey regarding feeding?
(a) Allow the infant 1 hour to complete each feeding.
(b) Position the infant in an upright position after each feeding.
(c) Give feedings per nasogastric tube to conserve energy.
(d) Provide a higher calorie formula or fortified breast milk.
Answer:
(d) Provide a higher calorie formula or fortified breast milk.
Explanation:
Infants with congenital heart disease often have difficulty feeding and gaining weight. They will tire quickly during the feeding. Most will do well with smaller, more frequent feedings. The infant with a congenital heart defect should not be given more than 20 minutes per feeding. Fortified breast milk or a high-calorie formula will help the infant gain weight and conserve energy.
Prolonging the feeding to an hour will merely tire the infant. Positioning the infant in an upright position is recommended for infants with gastro-intestinal reflux. Some infants with a congenital heart defect may not consume adequate amounts of calories through breast- or bottle-feeding and may require supplemental feeding through a nasogastric tube; however, nasogastric tube feedings are not necessary for all infants with congenital heart defects.
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