CH 22

Chapter 22: Pediatric Variations of Nursing Interventions
MULTIPLE CHOICE
1. Which should the nurse consider when having consent forms signed for surgery and
procedures on children?
Only a parent or legal guardian can give consent.
The person giving consent must be at least 18 years old.
The risks and benefits of a procedure are part of the consent process.
A mental age of 7 years or older is required for a consent to be considered
informed.
a.
b.
c.
d.
ANS: C
The informed consent must include the nature of the procedure, benefits and risks, and
alternatives to the procedure. In special circumstances, such as emancipated minors, the
consent can be given by someone younger than 18 years without the parent or legal guardian.
A mental age of 7 years is too young for consent to be informed.
PTS: 1
DIF: Cognitive Level: Understand
REF: 636
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care
2. The nurse is planning to prepare a 4-year-old child for some diagnostic procedures. Guidelines
for preparing this preschooler should include which action?

Plan for a short teaching session of about 30 minutes.
Tell the child that procedures are never a form of punishment.
Keep equipment out of the childs view.
Use correct scientific and medical terminology in explanations.
a.
b.
c.
d.
ANS: B
Illness and hospitalization may be viewed as punishment in preschoolers. Always state

directly that procedures are never a form of punishment. Teaching sessions for this age group
should be 10 to 15 minutes in length. Demonstrate the use of equipment, and allow the child
to play with miniature or actual equipment. Explain procedure in simple terms and how it
affects the child.
PTS: 1
DIF: Cognitive Level: Apply
REF: 639
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
3. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her
mother puts the hospital gown on her, but Katie is crying because she wants to leave on her
underpants. The most appropriate nursing action is to:
a. allow her to wear her underpants.
b. discuss with her mother why this is important to Katie.
c. ask her mother to explain to her why she cannot wear them.
d. explain in a kind, matter-of-fact manner that this is hospital policy.
ANS: A
It is appropriate for the child to leave her underpants on. This allows her some measure of
control in this procedure, foot surgery. Further discussions may make the child more upset.
Katie is too young to understand what hospital policy means.
PTS: 1
REF: 639-640
TOP: Integrated Process: Nursing Process: Implementation
4. Using knowledge of child development, which is the best approach when preparing a toddler
for a procedure?
Avoid asking the child to make choices.
Demonstrate the procedure on a doll.
Plan for teaching session to last about 20 minutes.
Show necessary equipment without allowing child to handle it.
a.
b.
c.
d.
ANS: B
Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the childs
favorite doll because the toddler may think the doll is really feeling the procedure. In
preparing a toddler for a procedure, allow the child to participate in care and help whenever
possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica
of the equipment, and allow the child to handle it.
PTS: 1
REF: 639
5. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. The girl tells the nurse
she wants her mother with her like before. The most appropriate nursing action is to:
grant her request.
explain why this is not possible.
identify an appropriate substitute for her mother.
offer to provide support to her during the procedure.
a.
b.
c.
d.
ANS: A
The parents preferences for assisting, observing, or waiting outside the room should be
assessed, along with the childs preference for parental presence. The childs choice should be
respected. If the mother and child are agreeable, then the mother is welcome to stay. An
appropriate substitute for the mother is necessary only if the mother does not wish to stay.
Support is offered to the child regardless of parental presence.
PTS: 1
REF: 638
6. The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child
whose mother is present. The child is crying and screaming loudly. The nurses action should
be to:
a. ask the child to be quieter.
b. have the childs mother give instructions about relaxation.
c. tell the child it is okay to cry and scream.
d. remove the mother from the room.
ANS: C
The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any
other emotion. The child needs to know it is all right to cry. There is no reason for the child to
be quieter and feelings need to be able to be expressed. The mother should stay in the room to
provide comfort to the child.
PTS: 1
REF: 641
7. In some genetically susceptible children, anesthetic agents can trigger malignant
hyperthermia. The nurse should be alert in observing that, in addition to an increased

temperature, an early sign of this disorder is:
a. apnea.
b. bradycardia.
c. muscle rigidity.
d. decreased blood pressure.
ANS: C
Early signs of malignant hyperthermia include tachycardia, increasing blood pressure,

tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia.
Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood
pressure, not decreased blood pressure, is characteristic of malignant hyperthermia.
PTS: 1
REF: 645-646
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
8. The nurse is caring for an unconscious child. Skin care should include which action?
a. Avoid use of pressure reduction on bed.
b. Massage reddened bony prominences to prevent deep tissue damage.
c. Use draw sheet to move child in bed to reduce friction and shearing injuries.
d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a
protective barrier.
ANS: C
A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction
and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices
should be used to redistribute weight. Bony prominences should not be massaged if reddened.
Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin
should be cleansed with mild nonalkaline soap or soap-free cleaning agents for routine
bathing.
PTS: 1
REF: 648
MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort
9. An appropriate intervention to encourage food and fluid intake in a hospitalized child is to:
a. force child to eat and drink to combat caloric losses.
b. discourage participation in noneating activities until caloric intake is sufficient.
c. administer large quantities of flavored fluids at frequent intervals and during meals.
d. give high-quality foods and snacks whenever child expresses hunger.

ANS: D
Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods
such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and
cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the
behavior as a control mechanism. Large quantities of fluid may decrease the childs hunger
and further inhibit food intake.
PTS: 1
REF: 649
10. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his
regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream.
Which is the best nursing action?
a. Request these favorite foods for him.
b. Identify healthier food choices that he likes.
c. Explain that he needs fruits and vegetables.
d. Reward him with ice cream at end of every meal that he eats.
ANS: A
Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate

nutrition, favorite foods should be requested for the child. These foods provide nutrition and
can be supplemented with additional fruits and vegetables. Ice cream and other desserts
should not be used as rewards or punishment.
PTS: 1
REF: 650
11. A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse,
reporting a fever of 102 F even though she had acetaminophen 2 hours ago. The nurses
action should be based on which statement?
a. Fevers such as this are common with viral illnesses.
b. Seizures are common in children when antipyretics are ineffective.
c. Fever over 102 F indicates greater severity of illness.
d. Fever over 102 F indicates a probable bacterial infection.
ANS: A
Most fevers are of brief duration, with limited consequences, and are viral. Little evidence
supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in
temperature nor its response to antipyretics indicates the severity or etiology of infection.
PTS: 1
REF: 650
12. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen (Tylenol). The nurse should explain that antipyretics:

a. may cause malignant hyperthermia.
b. may cause febrile seizures.
c. are of no value in treating hyperthermia.

d. are of limited value in treating hyperthermia.
ANS: C
Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already
normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy
that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics
do not cause seizures and are of no value in hyperthermia.
PTS: 1
REF: 650-651
MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies
13. Tepid water or sponge baths are indicated for hyperthermia in children. The nurses action is
to:
a.
b.
c.
d.
add isopropyl alcohol to the water.

direct a fan on the child in the bath.
stop the bath if the child begins to chill.
continue the bath for 5 minutes.
ANS: C
Environmental measures such as sponge baths can be used to reduce temperature if tolerated
by the child and if they do not induce shivering. Shivering is the bodys way of maintaining
the elevated set point. Compensatory shivering increases metabolic requirements above those
already caused by the fever. Ice water and isopropyl alcohol are potentially dangerous
solutions. Fans should not be used because of the risk of the child developing
vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to
the skin surface, and the blood remains primarily in the viscera to become heated. The child is
placed in a tub of tepid water for 20 to 30 minutes.
PTS: 1
REF: 651
14. The nurse approaches a group of school-age patients to administer medication to Sam Hart. To
identify the correct child, the nurses action is to:

ask the group, Who is Sam Hart?
call out to the group, Sam Hart?
ask each child, Whats your name?
check the patients identification name band.
a.
b.
c.
d.
ANS: D
The child must be correctly identified before the administration of any medication. Children
are not totally reliable in giving correct names on request; the identification bracelet should
always be checked. Asking children or the group for names is not an acceptable way to
identify a child. Older children may exchange places, give an erroneous name, or choose not
to respond to their name as a joke.
PTS: 1
REF: 665
MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control
15. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse
should:
wash hands thoroughly.
check the gloves for leaks.
rinse gloves in disinfectant solution.
apply new gloves before touching the next patient.
a.
b.
c.
d.
ANS: A
When gloves are worn, the hands are washed thoroughly after removing the gloves because
both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of
after use. Hands should be thoroughly washed before new gloves are applied.
PTS: 1
REF: 654
16. The nurse gives an injection in a patients room. The nurse should perform which intervention
with the needle for disposal?

a. Dispose of syringe and needle in a rigid, puncture-resistant container in patients
room.
b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area
outside of patients room.

c. Cap needle immediately after giving injection and dispose of in proper container.
d. Cap needle, break from syringe, and dispose of in proper container.
ANS: A
All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container
located near the site of use. Consequently, these containers should be installed in the patients
room. The uncapped needle should not be transported to an area distant from use. Needles are
disposed of uncapped and unbroken.
PTS: 1
REF: 654
17. A mother calls the outpatient clinic requesting information on appropriate dosing for over-the-
counter medications for her 13-month-old who has symptoms of an upper respiratory tract
infection and fever. The box of acetaminophen says to give 120 mg q4h when needed. At his
12-month visit, the nurse practitioner prescribed 150 mg. The nurses best response is:
a. The doses are close enough; it doesnt really matter which one is given.
b. It is not appropriate to use dosages based on age because children have a wide
range of weights at different ages.
c. From your description, medications are not necessary. They should be avoided in
children at this age.
d. The nurse practitioner ordered the drug based on weight, which is a more accurate
way of determining a therapeutic dose.
ANS: D
The method most often used to determine childrens dosage is based on a specific dose per
kilogram of body weight. The mother should be given correct information. For a therapeutic
effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve
discomfort in children at this age group.
PTS: 1
REF: 665
18. An 8-month-old infant is restrained to prevent interference with the IV infusion. The nurses
action is to:
a. remove the restraints once a day to allow movement.
b. keep the restraints on constantly.
c. keep the restraints secure so infant remains supine.
d. remove restraints whenever possible.
ANS: D
The nurse should remove the restraints whenever possible. When parents or staff are present,
the restraints can be removed and the IV site protected. Restraints must be checked and
documented every 1 to 2 hours. They should be removed for range of motion on a periodic
basis. The child should not be securely restrained in the supine position because of risks of
aspiration.
PTS: 1
REF: 656
19. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her
during the procedure. The nurse should recognize that this behavior is:
unsafe.
helpful to relax the child.
against hospital policy.
unnecessary because of childs age.
a.
b.
c.
d.
ANS: B
The mothers preference for assisting, observing, or waiting outside the room should be
assessed along with the childs preference for parental presence. The childs choice should be
respected. This will most likely help the child through the procedure. If the mother and child
agree, then the mother is welcome to stay. Her familiarity with the procedure should be
assessed and potential safety risks identified (mother may sit in chair). Hospital policies
should be reviewed to ensure that they incorporate family-centered care. The child should
determine whether parental support is necessary.
PTS: 1
REF: 641
20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When
preparing for a lumbar puncture, the nurses best action is to:

a. prepare child for conscious sedation during the test.
b. set up a tray with equipment the same size as for adults.
c. reassure the parents that the test is simple, painless, and risk free.
d. apply EMLA to puncture site 15 minutes before procedure.
ANS: A
Because of the urgency of the childs condition, conscious sedation should be used for the
procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the
parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does
have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of
anesthetics) should be applied approximately 60 minutes before the procedure. The
emergency nature of the spinal tap precludes its use.
PTS: 1
DIF: Cognitive Level: Analyze
REF: 641
21. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant.
Which is the most appropriate way to collect small amounts of urine for these tests?
a. Apply a urine-collection bag to perineal area.
b. Tape a small medicine cup to inside of diaper.
c. Aspirate urine from cotton balls inside diaper with a syringe.
d. Aspirate urine from superabsorbent disposable diaper with a syringe.
ANS: C
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly
from the diaper. If diapers with absorbent material are used, place a small gauze dressing or
cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For
frequent urine sampling, the collection bag would be too irritating to the childs skin. It is not
feasible to tape a small medicine cup to inside of diaper; the urine will spill from the cup.
Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
PTS: 1
REF: 659
22. Which is an important nursing consideration when performing a bladder catheterization on a
young boy?
Clean technique, not standard precautions, is needed.
Insert 2% lidocaine lubricant into the urethra.
Lubricate catheter with water-soluble lubricant such as K-Y Jelly.
Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.
a.
b.
c.
d.
ANS: B
The anxiety, fear, and discomfort experienced during catheterization can be significantly
decreased by preparation of the child and parents, by selection of the correct catheter, and by
appropriate technique of insertion. Generous lubrication of the urethra before catheterization
and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and
discomfort associated with this procedure. Catheterization is a sterile procedure, and standard
precautions for body-substance protection should be followed. Water-soluble lubricants do not
provide appropriate local anesthesia. Catheterization should be delayed 2 to 3 minutes only.
This provides sufficient local anesthesia for the procedure.
PTS: 1
REF: 660
23. The Allen test is performed as a precautionary measure before which procedure?
a. Heel stick
b. Venipuncture
c. Arterial puncture
d. Lumbar puncture
ANS: C
The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial
puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or
lumbar punctures.
PTS: 1
REF: 662
24. The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which is
recommended to facilitate this?

Apply cool, moist compresses.
Apply a tourniquet to ankle.
Elevate foot for 5 minutes.
Wrap foot in a warm washcloth.
a.
b.
c.
d.
ANS: D
Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10
minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood
collection more difficult. A tourniquet is used to constrict superficial veins. It will have an
insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot
available for collection.
PTS: 1
REF: 662
25. The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the
nurse do next?
Keep arm extended while applying a bandage to the site.
Keep arm extended, and apply pressure to the site for a few minutes.
Apply a bandage to the site, and keep the arm flexed for 10 minutes.
Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several
minutes.
a.
b.
c.
d.
ANS: B
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation.
Pressure should be applied before bandage is applied.
PTS: 1
REF: 662
26. A nurse must do a venipuncture on a 6-year-old child. Which is an important consideration in
providing atraumatic care?

Use an 18-gauge needle if possible.
If not successful after four attempts, have another nurse try.
Restrain child only as needed to perform venipuncture safely.
Show child equipment to be used before procedure.
a.
b.
c.
d.
ANS: C
Restrain child only as needed to perform the procedure safely; use therapeutic hugging. Use
the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable,
in which two operators each have only two attempts. If insertion is not successful after four
punctures, alternative venous access should be considered. Keep all equipment out of sight
until used.
PTS: 1
REF: 664
27. An appropriate method for administering oral medications that are bitter to an infant or small
child would be to mix them with:

a bottle of formula or milk.
any food the child is going to eat.
a small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream.
large amounts of water to dilute medication sufficiently.
a.
b.
c.
d.
ANS: C
Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will
make the medication more palatable to the child. The medication should be mixed with only a
small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to
determine how much medication was consumed. Medication should not be mixed with
essential foods and milk. The child may associate the altered taste with the food and refuse to
eat in the future.
PTS: 1
REF: 666
28. When liquid medication is given to a crying 10-month-old infant, which approach minimizes
the possibility of aspiration?

a. Administer the medication with a syringe (without needle) placed along the side of
the infants tongue.

b. Administer the medication as rapidly as possible with the infant securely restrained.
c. Mix the medication with the infants regular formula or juice and administer by
bottle.
d. Keep the child upright with the nasal passages blocked for a minute after
administration.
ANS: A
Administer the medication with a syringe without needle placed along the side of the infants
tongue. The contents are administered slowly in small amounts, allowing the child to swallow
between deposits. Medications should be given slowly to avoid aspiration. The medication
should be mixed with only a small amount of food or liquid. If the child does not finish
drinking or eating, it is difficult to determine how much medication was consumed. Essential
foods also should not be used. Holding the childs nasal passages will increase the risk of
aspiration.
PTS: 1
REF: 666
29. Which is the preferred site for intramuscular injections in infants?
a. Deltoid
b. Dorsogluteal
c. Rectus femoris
d. Vastus lateralis
ANS: D
The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used
for older children and adults. The rectus femoris is not a recommended site.
PTS: 1
REF: 667
30. Guidelines for intramuscular administration of medication in school-age children include
which action?
Inject medication as rapidly as possible.
Insert needle quickly, using a dartlike motion.
Penetrate skin immediately after cleansing site, before skin has dried.
Have child stand, if possible, and if child is cooperative.
a.
b.
c.
d.
ANS: B
The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless
contraindicated. Inject medications slowly. Allow skin preparation to dry completely before
skin is penetrated. Place child in lying or sitting position.
PTS: 1
REF: 671
31. Several types of long-term central venous access devices are used. Which is considered an
advantage of a Hickman-Broviac catheter?

No need to keep exit site dry
Easy to use for self-administered infusions
Heparinized only monthly and after each infusion
No limitations on regular physical activity, including swimming
a.
b.
c.
d.
ANS: B
The Hickman-Broviac catheter has several benefits, including that it is easy to use for selfadministered infusions. The exit site must be kept dry to decrease risk of infection. The
Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted
because of risk of infection.
PTS: 1
REF: 675
32. When teaching a mother how to administer eye drops, where should the nurse tell her to place
them?
a. In the conjunctival sac that is formed when the lower lid is pulled down
b. Carefully under the eye lid while it is gently pulled upward
c. On the sclera while the child looks to the side
d. Anywhere as long as drops contact the eyes surface
ANS: A
The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is
applied to this area. The medication should not be administered directly on the eyeball.
PTS: 1
REF: 679
33. A 2-year-old child comes to the emergency department with dehydration and hypovolemic
shock. Which best explains why an intraosseous infusion is started?

It is less painful for small children.
Rapid venous access is not possible.
Antibiotics must be started immediately.
Long-term central venous access is not possible.
a.
b.
c.
d.
ANS: B
In situations in which rapid establishment of systemic access is vital and venous access is
hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous
infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local
anesthetics and systemic analgesics are given. Antibiotics could be given when vascular
access is obtained. Long-term central venous access is time-consuming, and intraosseous
infusion is used in an emergency situation.
PTS: 1
REF: 682
TOP: Integrated Process: Nursing Process: Evaluation
34. When caring for a child with an intravenous infusion, the nurse should:
a. use a macrodropper to facilitate reaching the prescribed flow rate.
b. avoid restraining the child to prevent undue emotional stress.
c. change the insertion site every 24 hours.
d. observe the insertion site frequently for signs of infiltration.
ANS: D
The nursing responsibility for IV therapy is to calculate the amount to be infused in a given
length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to 2
hours) to make certain that the desired rate is maintained, the integrity of the system remains
intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the
infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in
pediatrics. The IV site should be protected. This may require soft restraints on the child.
Insertion sites do not need to be changed every 24 hours unless a problem is found with the
site. This exposes the child to significant trauma.
PTS: 1
REF: 683
35. Nursing considerations related to the administration of oxygen in an infant include to:
a. humidify oxygen if infant can tolerate it.
b. assess infant to determine how much oxygen should be given.
c. ensure uninterrupted delivery of the appropriate oxygen concentration.
d. direct oxygen flow so that it blows directly into the infants face in a hood.
ANS: C
Oxygen is a prescribed medication. It is the nurses responsibility to ensure that the ordered
concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the
tissues. Oxygen should always be humidified when delivered to a patient. A child receiving
oxygen therapy should have the oxygen saturation monitored at least as frequently as vital
signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage
as indicated. Humidified oxygen should not be blown directly into an infants face.
PTS: 1
REF: 687-688
36. It is important to make certain that sensory connectors and oximeters are compatible because
wiring that is incompatible can cause:

a. hyperthermia.
b. electrocution.
c. pressure necrosis.
d. burns under sensors.
ANS: D
It is important to make certain that sensor connectors and oximeters are compatible. Wiring
that is incompatible can generate considerable heat at the tip of the sensor, causing secondand third-degree burns under the sensor. Incompatibility would cause a local irritation or burn.
A low voltage is used, which should not present risk of electrocution. Pressure necrosis can
occur from the sensor being attached too tightly, but this is not a problem of incompatibility.
PTS: 1
REF: 689
37. The nurse is teaching a mother how to perform chest physical therapy and postural drainage
on her 3-year-old child, who has cystic fibrosis. To perform percussion, the nurse should
instruct her to:
a. cover the skin with a shirt or gown before percussing.
b. strike the chest wall with a flat-hand position.
c. percuss over the entire trunk anteriorly and posteriorly.
d. percuss before positioning for postural drainage.
ANS: A
For postural drainage and percussion, the child should be dressed in a light shirt to protect the
skin and placed in the appropriate postural drainage positions. The chest wall is struck with a
cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only.
Positioning precedes the percussion.
PTS: 1
REF: 689
38. The nurse must suction a child with a tracheostomy. Interventions should include:
a. encouraging child to cough to raise the secretions before suctioning.
b. selecting a catheter with diameter three fourths as large as the diameter of the
tracheostomy tube.
c. ensuring each pass of the suction catheter should take no longer than 5 seconds.
d. allowing child to rest after every five times the suction catheter is passed.
ANS: C
Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be
occluded for too long. If the child is able to cough up secretions, suctioning may not be
indicated. The catheter should have a diameter one half the size of the tracheostomy tube. If it
is too large, it might block the childs airway. The child is allowed to rest for 30 to 60 seconds
after each aspiration to allow oxygen tension to return to normal. Then the process is repeated
until the trachea is clear.
PTS: 1
REF: 691
39. When administering a gavage feeding to a school-age child, the nurse should:
a. lubricate the tip of the feeding tube with Vaseline to facilitate passage.
b. check the placement of the tube by inserting 20 ml of sterile water.
c. administer feedings over 5 to 10 minutes.
d. position on right side after administering feeding.
ANS: D
Position the child with the head elevated about 30 degrees and on the right side or abdomen
for at least 1 hour. This is in the same manner as after any infant feeding to minimize the
possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile
water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube,
while simultaneously listening with a stethoscope over the stomach area. Feedings should be
administered via gravity flow and take from 15 to 30 minutes to complete.
PTS: 1
REF: 700
40. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours,
the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the
ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse
during the next 8 hours?
a. 200 ml
b. 300 ml
c. 350 ml
d. 400 ml
ANS: B
The TPN infusion rate should not be increased or decreased without the practitioner being
informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes
from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.
PTS: 1
REF: 701
41. In preparing to give enemas until clear to a young child, the nurse should select which
solution?
Tap water
Normal saline
Oil retention
Fleet solution
a.
b.
c.
d.
ANS: B
Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is
not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid
overload. Oil-retention enemas will not achieve the until clear result. Fleet enemas are not
advised for children because of the harsh action of the ingredients. The osmotic effects of the
Fleet enema can result in diarrhea, which can lead to metabolic acidosis.
PTS: 1
REF: 701
42. The nurse is doing a prehospitalization orientation for a 7-year-old child who is scheduled for
cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk
because of an endotracheal tube but that she will be able to talk when it is removed. This
explanation is:
a. unnecessary.
b. the surgeons responsibility.
c. too stressful for a young child.
d. an appropriate part of the childs preparation.
ANS: D
Explanation is a necessary part of preoperative preparation. If the child wakes and is not
prepared for the inability to speak, she will be even more anxious. This is a necessary
component for preparation for surgery that will help reduce the anxiety associated with
surgery. It is a joint responsibility of nursing, medical staff, and child life personnel.
PTS: 1
REF: 640
MULTIPLE RESPONSE
1. The advantages of the ventrogluteal muscle as an injection site in young children include
which considerations? (Select all that apply.)

Less painful than vastus lateralis
Free of important nerves and vascular structures
Cannot be used when child reaches a weight of 20 pounds
Increased subcutaneous fat, which increases drug absorption
Easily identified by major landmarks
a.
b.
c.
d.
e.
ANS: A, B, E
The advantages of the ventrogluteal are being less painful, free of important nerves and
vascular lateralis, and is easily identified by major landmarks. The major disadvantage is lack
of familiarity by health professionals and controversy over whether the site can be used before
weight bearing. The use of the ventrogluteal has not been clarified. It has been used in infants,
but clinical guidelines address the need for the child to be walking, thus generally being over
20 pounds. The site has less subcutaneous tissue, which facilitates intramuscular (rather than
subcutaneous) deposition of the drug.
PTS: 1
REF: 667
2. A nurse is caring for a child in droplet precautions. Which instructions should the nurse give
to the unlicensed assistive personnel caring for this child? (Select all that apply.)
a. Wear gloves when entering the room.
b. Wear an isolation gown when entering the room.
c. Place the child in a special air handling and ventilation room.
d. A mask should be worn only when holding the child.
e. Wash your hands upon exiting the room.
ANS: A, B, E
Droplet transmission involves contact of the conjunctivae or the mucous membranes of the
nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing
microorganisms generated from a person who has a clinical disease or who is a carrier of the
microorganism. Droplets are generated from the source person primarily during coughing,
sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves,
gowns, and a mask should be worn when entering the room. Handwashing when exiting the
room should be done with any patient. Because droplets do not remain suspended in the air,
special air handling and ventilation are not required to prevent droplet transmission.
PTS: 1
REF: 654

COMPLETION
1. A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin).
The dosage is 0.07 mg/kg/day, and the childs weight is 7.2 kg. The physician prescribes the
digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your
answer below using one decimal place.)
ANS:
0.5
Calculate the dosage by weight: 0.07 mg/day 7.2 kg = 0.5 mg/day.
PTS: 1
REF: 665
2. A physicians prescription reads, ampicillin sodium 125 mg IV every 6 hours. The
medication label reads, 1 g = 7.4 ml. A nurse prepares to draw up _____ milliliters to
administer one dose. (Round your answer to two decimal places.)
ANS:
0.93
Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000
or move the decimal point three places to the right.
1 g = 1000 mg
Formula:
Desired Volume = 125 mg/1000 mg 7.4 ml = 0.925 round to 0.93 ml.
Available
PTS: 1
REF: 665
SHORT ANSWER
1. A 6-month-old infant is admitted to the pediatric unit with respiratory syncytial virus (RSV).
The nurse places the infant on strict intake and output. The infant is in a size #2 diaper and the
dry weight is 24 g. At the end of the shift, the infant has had two diapers with urine. One
diaper weighed 56 g and one weighed 65 g. What is the total milliliter output for the shift?
(Record your answer as a whole number below.)
ANS:
73
1 g of wet diaper weight = 1 ml of urine.
The dry weight of the diaper is 24 g.
56 g 24 g = 32 ml.
65 g 24 g = 41 ml.
32 ml + 24 ml = 73 ml total output for the shift.
PTS: 1
REF: 681
ESSAY
1. The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent
suctioning after abdominal surgery. Place in correct sequence the steps for inserting a
nasogastric tube. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d,
e, f).
a. Lubricate the nasogastric tube with water-soluble lubricant.
b. Tape the nasogastric tube securely to the childs face.
c. Check the placement of the tube by aspirating stomach contents.
d. Place the child in the supine position with head slightly hyperflexed.
e. Insert the nasogastric tube through the nares.
f. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid
process and the umbilicus.
ANS:
d, f, a, e, c, b
PTS: 1
DIF: Cognitive Level: Remember
REF: 697

CH 22

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CH 22

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Chapter 22: Pediatric Variations of Nursing Interventions

for preparing this preschooler should include which action?

Illness and hospitalization may be viewed as punishment in preschoolers. Always state

hyperthermia. The nurse should be alert in observing that, in addition to an increased

Early signs of malignant hyperthermia include tachycardia, increasing blood pressure,

d. give high-quality foods and snacks whenever child expresses hunger.

Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate

acetaminophen (Tylenol). The nurse should explain that antipyretics:

c. are of no value in treating hyperthermia.

add isopropyl alcohol to the water.

identify the correct child, the nurses action is to:

with the needle for disposal?

outside of patients room.

preparing for a lumbar puncture, the nurses best action is to:

recommended to facilitate this?

26. A nurse must do a venipuncture on a 6-year-old child. Which is an important consideration in

providing atraumatic care?

child would be to mix them with:

the possibility of aspiration?

the infants tongue.

advantage of a Hickman-Broviac catheter?

shock. Which best explains why an intraosseous infusion is started?

wiring that is incompatible can cause:

which considerations? (Select all that apply.)

DIF: Cognitive Level: Apply

TOP: Integrated Process: Nursing Process: Implementation

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