Pediatric Nursing An Introductory Text 11th edition by Debra L. Price-Test Bank
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Price: Pediatric Nursing, 11th Edition
Chapter 03: Pediatric Procedures
Testbank
MULTIPLE CHOICE
1. As
part of the preparation for obtaining a throat swab from a toddler, the nurse
will:
|
a. |
Bring all equipment to the
bedside prior to explaining the procedure to the child |
|
b. |
Tell the toddler several
hours in advance |
|
c. |
Have the parent restrain
the child |
|
d. |
Give a brief simple explanation
to the child |
ANS: D
The toddler should receive a simple explanation just before the
procedure. The equipment should not be brought to the bedside until
explanations have been given to the child and the parent. The parents can hold
the child but should not be seen as the restrainer.
DIF: Cognitive Level:
Application
REF: p.
33
OBJ: 2
TOP: Preparation for
Procedures
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
2. The
nurse is aware that the most effective form of comfort for an 11-year-old
school-age child after a painful procedure is:
|
a. |
Therapeutic holding by the
parent |
|
b. |
Praise for cooperation |
|
c. |
A Mickey Mouse sticker |
|
d. |
A lollipop |
ANS: B
The older school-age child responds well to praise. Therapeutic
holding, candy, and colorful stickers are childish.
DIF: Cognitive Level:
Application
REF: p.
33
OBJ: 2
TOP: Preparation for
Procedures
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
3. In
demonstrating technique for bathing an infant, the home health nurse stresses
to the parents considerations such as:
|
a. |
Always run hot water first
to prevent chilling |
|
b. |
Wrap the circumcised penis
in waterproof plastic |
|
c. |
Apply lotions, not powder,
after the bath |
|
d. |
Mild bubble bath will
lubricate the skin |
ANS: C
Use lotions rather than powder due to the risk of aspiration.
Cold water should be run in the tub first. Circumcised infants should be
sponged until circumcision is healed. Bubble baths may cause vaginitis in
infants.
DIF: Cognitive Level:
Application
REF: pp.
34-35 OBJ: 3
TOP: Bathing an Infant or Small
Child KEY: Nursing Process
Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance: Basic
Care and Comfort
4. Prior
to obtaining a clean-catch specimen from a 4-year-old, the nurse could best get
the child to comply by:
|
a. |
Telling the child to void
in the cup |
|
b. |
Using the term the child
uses for urination in explanations |
|
c. |
Gently washing the
perineum, holding the cup in place, and asking the child to void |
|
d. |
Catheterizing the child |
ANS: B
The child will not understand what a clean-catch urine specimen
is, so the nurse should explain to the child what is needed. The nurse should
discover what term the child uses for urination, because the other terms may
also be meaningless. Catheterization is unnecessary.
DIF: Cognitive Level:
Application
REF: pp.
36-37 OBJ: 4
TOP: Collection of
Specimens
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
5. A
child with spina bifida requires home catheterization. The child is now old
enough to learn how to perform this procedure himself. The child is taught:
|
a. |
Clean the tip of the penis
with soap and water or Betadine |
|
b. |
Insert the catheter 3
inches |
|
c. |
Do not lubricate the
catheter if reusing |
|
d. |
Never reuse the catheter |
ANS: A
The tip of the penis should be cleaned with soap and water or
Betadine. The catheter should be inserted until urine is returned. Always
lubricate the catheter before insertion. The catheter can be cleaned, dried,
and reused for 1 week without increasing the risk of infection.
DIF: Cognitive Level:
Application
REF: p.
39
OBJ: 4
TOP: Specimen
Collection
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
6. In
order to lessen the discomfort of a venipuncture for a blood draw for a
3-year-old child, the nurse may apply EMLA (local anesthetic cream) to the
antecubital fossa:
|
a. |
Immediately prior to
venipuncture |
|
b. |
10 minutes prior to
venipuncture |
|
c. |
30 minutes prior to
venipuncture |
|
d. |
60 minutes prior to
venipuncture |
ANS: D
EMLA cream should be applied 60 minutes prior to venipuncture.
Children older than 2 years of age usually have blood drawn from the
antecubital fossa.
DIF: Cognitive Level:
Application
REF: p.
40
OBJ: 5
TOP: Collection of Blood Specimens
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
7. After
a blood draw from the antecubital fossa of a 5-year-old child, the child
continues to cry and to press his hand against the puncture site. The nurse’s
best intervention would be to say:
|
a. |
“Big kids don’t cry. It is
all over, and you are just fine. Let’s go to the playroom.” |
|
b. |
“This big band aid will fix
that hole, and you won’t have to hold it anymore. You were very brave!” |
|
c. |
“Tell this stuffed bear how
much that needle sticking in your arm hurt.” |
|
d. |
“Let’s go get some ice to
put on that hole in your arm.” |
ANS: B
Preschoolers may fear continuously losing blood from the
puncture site. The placement of a large bandage reassures them that their body
fluids will not leak out.
DIF: Cognitive Level:
Application
REF: p.
40
OBJ: 5
TOP: Collection of
Blood
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
8. The
nurse while assisting the physician with a lumbar puncture of a small child
will take special precaution to closely monitor the:
|
a. |
Blood pressure |
|
b. |
Pulse |
|
c. |
Respiratory status |
|
d. |
Temperature |
ANS: C
The nurse would monitor the respiratory status of the child
during the procedure. Respiratory obstruction is a risk when the neck is
flexed. The other vital signs would be monitored before the beginning of the
procedure.
DIF: Cognitive Level:
Application
REF: p.
42
OBJ: 6
TOP: Assisting with Lumbar
Puncture KEY: Nursing
Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Safety
and Infection Control
9. In
order to prepare a child for a lumbar puncture, the nurse would place the child
in which position?
|
a. |
Supine |
|
b. |
Side-lying in the center of
the table with knees flexed |
|
c. |
Seated with legs dangling
and neck flexed |
|
d. |
Side-lying with neck and
knees held in flexed position |
ANS: D
The nurse can place the child in either a side-lying position
with knees flexed, or a seated position with the back curved on the edge of the
examination table.
DIF: Cognitive Level:
Application
REF: p.
42
OBJ: 6
TOP: Assisting with Lumbar
Puncture KEY: Nursing
Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Safety
and Infection Control
10. Following
a successful lumbar puncture, in order to avoid post-procedure discomfort for
the patient, the nurse should:
|
a. |
Ask the parents to keep the
child flat for several hours |
|
b. |
Encourage the child to
begin ambulation as soon as possible |
|
c. |
Place the child in the high
Fowler’s position for several hours |
|
d. |
Place the child in the
semi-Fowler’s position with knees flexed for several hours |
ANS: A
The child is instructed to lay flat for a certain amount of time
in order to decrease the chance of developing a spinal headache. Ambulation and
a high Fowler’s position would increase the likelihood of having a spinal
headache.
DIF: Cognitive Level:
Application
REF: p.
42
OBJ: 6
TOP: Assisting with Lumbar
Puncture KEY: Nursing
Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
11. The
nurse sees an order to give 500 mg of an oral suspension of Ampicillin to a
child who weighs 22 pounds. After the nurse has calculated the dose based on
the child’s weight and sees that the dose should be 50 mg/kg/day, the nurse
should:
|
a. |
Tell the charge nurse that
the dose seems too high |
|
b. |
Call the physician to
clarify the order |
|
c. |
Give the ordered dose |
|
d. |
Ask the parents if the
child has taken this much drug previously |
ANS: C
The nurse should calculate the child’s weight in kilograms and
compare with the recommended dose. 22 pounds child weight = 10 kilograms; 10
kilograms multiplied by 50 mg = 500 mg. The ordered dose should be given.
DIF: Cognitive Level: Application
REF: p.
42
OBJ: 7
TOP: Administering
Medication
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
12. The
nurse has drawn up 5 units of insulin to give to an 8-year-old. As a safety
precaution prior to giving the drug, the nurse should:
|
a. |
Ask the parent if the child
has ever had an insulin reaction |
|
b. |
Check the child’s blood
sugar |
|
c. |
Verify the dose with
another nurse |
|
d. |
Chart the administration of
the drug |
ANS: D
Prior to giving drugs such as digoxin, insulin, heparin, and
narcotics, the dose is verified by another nurse. There is no need to check the
blood sugar at this time. Drugs are never charted until they are actually given.
DIF: Cognitive Level:
Application
REF: p.
44
OBJ: 7
TOP: Administering
Medication
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Safety
and Infection Control
13. The
nurse brings the medication into a child’s room for administration. The
intervention that will ensure safe administration of this medication is:
|
a. |
Call the child by name to
verify the patient’s identity |
|
b. |
Verify the patient’s identity
with the hospital identification band for child’s birth date |
|
c. |
Inform the parent about the
side effects of the drug |
|
d. |
Ask another nurse to verify
the child’s identity |
ANS: B
The nurse should not rely on the child for verification of
identity. The identity should be confirmed by comparing the hospital
identification band and a second identifier, such as birth date or room number.
DIF: Cognitive Level:
Application
REF: p.
44
OBJ: 7
TOP: Administering
Medication
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Safety
and Infection Control
14. The
nurse caring for a 2-month-old baby uses a(n) __________ to administer a very
small dose of oral medication that is in a suspension.
|
a. |
Oral syringe |
|
b. |
Calibrated cup |
|
c. |
Teaspoon |
|
d. |
Nipple |
ANS: A
The nurse would use an oral syringe, because it is the most
accurate. Teaspoons are often inaccurate and do not hold a standard amount. It
is hard to be accurate with a small dose using a calibrated cup. The nipple is
useful but does not have anything to do with accuracy.
DIF: Cognitive Level:
Application
REF: p.
44
OBJ: 7
TOP: Medication
Administration
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
15. An
intramuscular (IM) injection is ordered for a 6-month-old child. The nurse
should select the injection site of:
|
a. |
Dorsogluteal |
|
b. |
Ventrogluteal |
|
c. |
Vastus lateralis |
|
d. |
Deltoid |
ANS: C
The nurse would choose the vastus lateralis because it is
well-developed at birth, it is the largest muscle mass, and it has the fewest
vessels and nerves. The dorsogluteal is not fully developed until the child has
walked for 1 to 2 years. The ventrogluteal should not be used until 18 months.
The deltoid cannot be used for large volumes of medication or for medications
that need to be administered into the deep muscle mass.
DIF: Cognitive Level:
Application
REF: p.
47
OBJ: 8
TOP: Intramuscular
Injections
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
16. The
nurse giving an intramuscular (IM) dose of 2 mL to a 6-month-old child should:
|
a. |
Inject the entire amount in
the ventrogluteal muscle |
|
b. |
Give the medication in
divided doses in each deltoid |
|
c. |
Inject 1 mL into each
vastus lateralis |
|
d. |
Divide the dose, and give 1
mL injections 1 hour apart |
ANS: C
The nurse should divide the dose and give the maximum 1 mL in
each vastus lateralis.
DIF: Cognitive Level:
Application
REF: p. 47
OBJ: 8
TOP: Intramuscular
Injections
KEY: Nursing Process Step: Application
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
17. The
nurse is aware that an IV antibiotic medication should infuse in no longer
than:
|
a. |
15 minutes |
|
b. |
30 minutes |
|
c. |
45 minutes |
|
d. |
60 minutes |
ANS: D
An antibiotic medication should infuse in no longer than 60
minutes.
DIF: Cognitive Level:
Comprehension REF: p.
49
OBJ: 9
TOP: Intravenous
Medication
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
18. An
infant with diarrhea is dehydrated. IV fluids have been ordered to restore
fluid balance. The most effective device used to prevent fluid overload is:
|
a. |
A precision-controlled
syringe pump |
|
b. |
A piggyback setup |
|
c. |
A tunneled IV catheter |
|
d. |
A 15-drop infusion set |
ANS: A
A syringe or other in-line volume-control device is often used
because they hold a limited amount of fluid. Only that fluid can be
administered at one time. A piggyback setup would be used to infuse a dose of
medication, not a continuous infusion. Neither a tunneled catheter nor a
15-drop infusion set would protect the child from fluid overload.
DIF: Cognitive Level:
Application
REF: p.
49
OBJ: 9
TOP: Parenteral
Fluids
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Safety
and Infection Control
19. The
nurse monitoring the TPN infusion for a small child assesses that the infusion
is behind. The nurse should:
|
a. |
Speed up the infusion to
catch up |
|
b. |
Notify the charge nurse |
|
c. |
Stop the infusion, and
notify the charge physician |
|
d. |
Give the child extra fluids
to make up for the deficit |
ANS: B
TPN must be monitored carefully. Speeding up an infusion can
cause hyperglycemia. The infusion should not be stopped. The charge nurse
should be notified.
DIF: Cognitive Level:
Application
REF: p.
50
OBJ: 9
TOP: Total Parenteral
Nutrition
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
20. Following
a gavage feeding, a 4-year-old child should be positioned:
|
a. |
In a high Fowler’s position
to prevent aspiration |
|
b. |
In a semi-Fowler’s position
with knees flexed to prevent cramping |
|
c. |
On the right side to aid in
stomach emptying |
|
d. |
On the left side to slow
stomach emptying |
ANS: C
After a gavage feeding, the child is positioned on the right
side to aid in stomach emptying.
DIF: Cognitive Level:
Comprehension REF: p. 51
OBJ: 10
TOP: Gavage
Feedings
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
21. When
the nurse is instilling drops into the ear of a 2-year-old, the nurse should:
|
a. |
Pull the earlobe up |
|
b. |
Chill the drops prior to
administration |
|
c. |
Assist the child to sit
upright after instillation |
|
d. |
Draw the earlobe down and
back to straighten the ear canal |
ANS: D
For a child younger than 3 years of age, the earlobe is drawn
down and back to straighten the ear canal and allow the drops to enter the ear
canal. The child should be left in a supine or side-lying position while the
drops are absorbed. The drops should be warmed.
DIF: Cognitive Level:
Application
REF: p.
46
OBJ: 7
TOP: Topic: Administration of
Eardrops KEY: Nursing Process Step:
Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
22. The
nurse modifies the technique of administering eyedrops for a 1-month-old infant
by:
|
a. |
Placing the drops in the
nasal corner of the eyelid |
|
b. |
Asking assistance of a
coworker to hold the lids open |
|
c. |
Grasping the eyelashes and
placing the drops under the lid |
|
d. |
Applying the drops from a
moistened cotton ball |
ANS: A
Because infants clench their eyes shut, the drops can be placed
in the nasal corner of the eye so when the child opens the eyes the medication
flows onto the conjunctiva.
DIF: Cognitive Level:
Application
REF: p.
47
OBJ: 7
TOP: Topic: Infant
Eyedrops
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
COMPLETION
1. Carrying
out procedures in the least stressful manner to the child is called
___________.
ANS:
Atraumatic care
Considering the least painful or stressful method to complete a
procedure is classified as atraumatic care.
DIF: Cognitive Level:
Knowledge
REF: p.
33
OBJ: 2
TOP: Preparation for
Procedures
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Basic Care and
Comfort
2. When
parenteral fluids have escaped into the surrounding tissue, the nurse would
document and report that ___________ had occurred.
ANS:
Extravasation or infiltration
Extravasation is the term for escaped
parenteral fluid that has entered the surrounding tissue.
DIF: Cognitive Level:
Knowledge
REF: p.
50
OBJ: 1
TOP:
Extravasation
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
3. A
catheter threaded into the superior vena cava for the purpose of parenteral
nutrition (TPN) is referred to as a(n) ___________.
ANS:
PICC or peripherally inserted central catheter
A PICC is inserted into the antecubital area and threaded into
the superior vena cava, and it can be used for long-term parenteral therapy.
DIF: Cognitive Level:
Knowledge
REF: p.
50
OBJ: 9
TOP:
PICC
KEY: Nursing Process Step:
N/A
MSC: NCLEX: N/A
4. For a
child who weighs 32 pounds, what is the maximum pediatric dose for a medication
that is recommended to be given at 35 mg/kg/day?
ANS:
507.5 mg
RAT: 32 pounds divided by 2.2 = 14.5 kilograms; 14.5 kilograms
multiplied by 35 = 507.5 mg.
DIF: Cognitive Level:
Application
REF: p. 42
OBJ: 7
TOP: Topic: Dose
calculation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
5. When
selecting a cuff for a child, the nurse should confirm that the width of the
cuff covers approximately ____________ of the upper arm.
ANS:
Two thirds
A cuff that is too large will give an erroneously low reading.
DIF: Cognitive Level:
Comprehension REF: p.
60
OBJ: 14
TOP: Blood Pressure Cuff
Width
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
6. When
preparing an enema solution for a child younger than 2 years of age, the total
amount of fluid should not exceed ____________.
ANS:
240 mL
Children younger than 2 years of age should not receive more
than 240 mL of fluid in an enema solution.
DIF: Cognitive Level:
Comprehension REF: p.
51
OBJ: 2
TOP: Enema
Volume
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
MULTIPLE RESPONSE
1. The
nurse giving an allergy desensitization injection to a well-fed 8-month-old
child in a subcutaneous injection would: (Select
all that apply.)
|
a. |
Select a 23-gauge needle |
|
b. |
Inject at a 90-degree angle |
|
c. |
Gently aspirate before
injecting the medicine |
|
d. |
Give a maximum of 1 mL |
|
e. |
Give the injection in the
abdomen |
ANS: B, E
A dose of no more than 0.05 mL can be delivered with a 25- to 27-gauge
needle, usually in the abdomen at a 90-degree angle without aspiration.
DIF: Cognitive Level:
Application
REF: p.
35
OBJ: 8
TOP: Topic: Subcutaneous
Injections KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
2. The
nurse would assess a 5-year-old patient who had a lumbar puncture completed 30
minutes ago for: (Select
all that apply.)
|
a. |
Drainage at the puncture
site |
|
b. |
Evidence of headache |
|
c. |
Elevation of temperature |
|
d. |
Allergic skin reaction |
|
e. |
Gastric distress |
ANS: A, B, C
Following a lumbar puncture, the patient should be assessed for
drainage at the puncture site, evidence of post-puncture headache, or elevation
of temperature. Allergic skin reaction and gastric distress are not associated
with post-lumbar puncture concerns.
DIF: Cognitive Level:
Application
REF: p.
48
OBJ: 6
TOP: Assisting with Lumbar
Puncture KEY: Nursing
Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
3. Considerations
about possible risk factors of giving medications to children include: (Select all that apply.)
|
a. |
Smaller body mass of a
child |
|
b. |
Immaturity of body systems |
|
c. |
Need for individuality of
dose |
|
d. |
High toxicity of many
modern drugs |
|
e. |
Unavailability of useful
drug references |
ANS: A, B, C, D
Medicating small children is hazardous because of their smaller
body mass, the immaturity of their body systems, the need for individualizing
doses, and the high toxicity of many modern drugs. Many drug references are
available.
DIF: Cognitive Level:
Comprehension REF: p.
42
OBJ: 7
TOP: Administering
Medication
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
4. The
signs that indicate the need for tracheal suctioning in a 3-month-old child
are:
|
a. |
Coughing |
|
b. |
Crust around the
tracheostomy tube |
|
c. |
A bubbling sound during
respiration |
|
d. |
Noisy breathing |
|
e. |
Moisture on a dressing
under the tracheostomy tube |
ANS: A, C, D
Coughing, a bubbling sound during respiration, and noisy
breathing are indicators of the need for tracheostomy suctioning. Crust on the
tube and a moist dressing can be remedies when the tube is cleaned and are not
indicators of obstruction.
DIF: Cognitive Level:
Application
REF: p.
42
OBJ: 11
TOP: Suctioning
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
OTHER
1. Place
the steps of the infant bath in the correct sequence:
2. Apply
water and shampoo to the head, and shampoo the hair/scalp
3. Fill
the tub, and test the water for appropriate warmth
4. Remove
secretions from the baby’s eyes
5. Bathe
the trunk and limbs
6. Wash
the perineal area
ANS:
B, C, A, D, E
The water is run and tested for appropriate warmth (100° F). The
eyes are cleansed using a separate cotton ball for each eye, the face is
washed, the hair/scalp is shampooed, the trunk and limbs are washed, the
perineum is washed, and the baby is wrapped in a towel to dry.
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