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Maternal Child Nursing Test Bank: Pediatric Interventions

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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
Chapter 39: Pediatric Variations of Nursing Interventions
Perry: Maternal Child Nursing Care, 6th Edition
MULTIPLE CHOICE
1. What should the nurse consider when having consent forms signed for surgery and procedures
on children?
a. Only a parent or legal guardian can give consent.
b. The person giving consent must be at least 18 years old.
c. The risks and benefits of a procedure are part of the consent process.
d. A mental age of 7 years or older is required for a consent to be considered
“informed.”
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: Comprehension
MSC: Client Needs: Safe and Effective Care Environment
OBJ: Nursing Process: Planning
2. The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures.
What guideline should the nurse consider when preparing a preschooler for a diagnostic
procedure?
a. Planning for a short teaching session
of about 30 minutes.
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b. Telling the child that procedures are never a form of punishment.
c. Keeping equipment out of the child’s view.
d. Using correct scientific and medical terminology in explanations.
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 the procedure and how it affects the child in
simple terms.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
3. The most appropriate nursing action to implement when a preschooler being prepped for
outpatient surgery refused to allow the parent to remove his/her underwear?
a. Allow the child to wear their underpants.
b. Discuss to the mother why this is important.
c. Ask the mother to explain to her child why he/she must remove the underwear.
d. Explain in a kind, matter-of-fact manner that this is hospital policy.
ANS: A
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
It is appropriate for the child to leave his/her underpants on. This allows his/her some measure
of control during the foot surgery. The mother should not be required to make the child more
upset. The child is too young to understand what hospital policy means.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
4. Using knowledge of child development, what is the best approach when preparing a toddler
for a procedure?
a. Avoid asking the child to make choices.
b. Demonstrate the procedure on a doll.
c. Plan for the teaching session to last about 20 minutes.
d. Show necessary equipment without allowing child to handle it.
ANS: B
Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child’s
favorite doll because the toddler may think the doll is really “feeling” the procedure. In
preparing a toddler for a procedure, the child is allowed 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
DIF: Cognitive Level: Application
MSC: Client Needs: Health Promotion and Maintenance
OBJ: Nursing Process: Planning
5. The nurse is cleaning multiple facial abrasions on a 9-year-old who was brought to the
emergency department by his/her mother. When the child begins crying and screaming loudly,
what intervention should the nurse implement to best manage this situation?
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a. Calmly ask the child to be quieter.
b. Suggest that his/her mother help the child to relax.
c. Tell the child it is okay to cry and scream.
d. Suggest that he/she talk to his/her mother as a form of distraction.
ANS: C
The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any
other emotion. The child needs to know that it is all right to cry. There is no reason for him to
be quieter. He is too upset and needs to be able to express his feelings.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
6. The nurse monitoring a child for signs and symptoms of malignant hyperthermia should be
alert for which early sign of this disorder?
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, not
decreased, blood pressure is characteristic of malignant hyperthermia.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
PTS: 1
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
7. The nurse is caring. What skin care interventions for an unconscious child should be included
in the plan of care?
a. Avoiding use of pressure reduction on the bed.
b. Massaging reddened bony prominences to prevent deep tissue damage.
c. Using drawsheet to move child in bed to reduce friction and shearing injuries.
d. Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a
protective barrier.
ANS: C
A drawsheet 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. Bony prominences should
not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices
should be used to redistribute weight instead. The skin should be cleansed with mild
nonalkaline soap or soap-free cleaning agents for routine bathing.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
8. What is an appropriate intervention to encourage food and fluid intake in a hospitalized child?
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.
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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, 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 child’s hunger
and further inhibit food intake.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
9. A 3 year old has a 102° F fever associated with a viral illness that has not responded to
acetaminophen. The nurse’s action should be based on what knowledge about fevers in
children?
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, have 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.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
PTS: 1
DIF: Cognitive Level: Comprehension
MSC: Client Needs: Physiologic Integrity
OBJ: Nursing Process: Diagnosis
10. What intervention is appropriate when administering tepid water or sponge baths prescribed
for hyperthermia in children?
a. Add isopropyl alcohol to the water.
b. Direct a fan on the child in the bath.
c. Stop the bath if the child begins to chill.
d. 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 body’s 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 inappropriate, 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
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
11. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse
should perform which initial action?
a. Wash hands thoroughly.
b. Check the gloves for leaks.
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c. Rinse gloves in disinfectant solution.
d. Apply new gloves before touching the next patient.
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 and hands should be thoroughly washed again before new gloves are applied.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
12. The nurse gives an injection in a patient’s room. Which method should the nurse use to
dispose of the needle?
a. Dispose of syringe and needle in a rigid, puncture-resistant container in patient’s
room.
b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area
outside of patient’s 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 patient’s
room. The uncapped needle should not be transported to an area distant from use.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
13. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant.
How should the nurse collect small amounts of urine for these tests?
a. Apply a urine-collection bag to the perineal area.
b. Tape a small medicine cup to the inside of the diaper.
c. Aspirate urine from cotton balls inside the diaper with a syringe.
d. Aspirate urine from a 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 child’s skin. Taping a
small medicine cup to the inside of the diaper is not feasible; the urine will spill from the cup.
Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
14. What is an important nursing consideration when performing a bladder catheterization on a
young boy?
a. Use clean technique, not Standard Precautions.
b. Insert 2% lidocaine lubricant into the urethra.
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c. Lubricate catheter with water-soluble
lubricant such as K-Y Jelly.
d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.
ANS: B
The anxiety, fear, and discomfort experienced during catheterization can be significantly
decreased by preparing the child and parents, selecting the correct catheter, and using
appropriate insertion technique. 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 only 2 to 3
minutes. This provides sufficient local anesthesia for the procedure.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
15. What is the most appropriate statement for the nurse to make to a 5-year-old child who is
undergoing a venipuncture?
a. “You must hold still or I’ll have someone hold you down. This is not going to
hurt.”
b. “This will hurt like a pinch. I’ll get someone to help hold your arm still so it will
be over fast and hurt less.”
c. “Be a big boy and hold still. This will be over in just a second.”
d. “I’m sending your mother out so she won’t be scared. You are big, so hold still and
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
this will be over soon.”
ANS: B
Honesty is the best approach. Children should be told what sensation they will feel during a
procedure. A 5-year-old child should not be expected to hold still, and assistance ensures
safety to everyone. Telling the child that “This will be over in just a second” is not supportive
or honest. Parents should be encouraged to remain with the child unless they are extremely
uncomfortable doing so.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
16. What important consideration in providing atraumatic care should the nurse consider when
preforming a venipuncture on a 6-year-old child?
a. Use an 18-gauge needle if possible.
b. If not successful after four attempts, have another nurse try.
c. Restrain the child only as needed to perform venipuncture safely.
d. Show the child equipment to be used before procedure.
ANS: C
Restrain the child only as needed to perform the procedure safely; an alternative would be the
use of 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
DIF: Cognitive Level: Application
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OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
17. The nurse administering a bitter oral medication to an infant or small child should mix the
medication with what substance?
a. A bottle of formula or milk.
b. Any food the child is going to eat.
c. A teaspoon of jam or ice cream.
d. Large amounts of water to dilute medication sufficiently.
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/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 future.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
18. When liquid medication is given to a crying 10-month-old infant, which approach minimizes
the possibility of aspiration?
a. Administering the medication with a syringe (without needle) placed along the side
of the infant’s tongue.
b. Administering the medication as rapidly as possible with the infant securely
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
restrained.
c. Mixing the medication with the infant’s regular formula or juice and administering
by bottle.
d. Keeping the child upright with the nasal passages blocked for a minute after
administration.
ANS: A
Administer the medication with a syringe without needle placed alongside of the infant’s
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/eating, it is difficult to determine how much medication was consumed. Essential
foods also should not be used. The child may associate the altered taste with the food and
refuse to eat in future. Holding the child’s nasal passages increases the risk of aspiration.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
19. Guidelines for intramuscular administration of medication in school-age children include what
instruction?
a. Inject medication as rapidly as possible.
b. Insert the needle quickly, using a dart-like motion.
c. Penetrate the skin immediately after cleansing the site, before skin has dried.
d. Have the child stand, if possible, and if he or she is cooperative.
ANS: B
The needle should be inserted quickly in a dart-like motion at a 90-degree angle unless
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contraindicated. Inject medications
slowly. Allow skin preparation to dry completely before
skin is penetrated. Place the child in a lying or sitting position.
PTS: 1
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
20. When teaching a mother how to administer eyedrops, where should the nurse instruct to place
them?
a. In the conjunctival sac that is formed when the lower lid is pulled down.
b. Carefully under the upper eyelid 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 eye’s 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
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
21. A 2-year-old child comes to the emergency department demonstrating signs of dehydration
and hypovolemic shock. Which best explains why an intraosseous infusion is started?
a. It is less painful for small children.
b. Rapid venous access is not possible.
c. Antibiotics must be started immediately.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
d. Long-term central venous access is not possible.
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
anesthesia and systemic analgesia 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
DIF: Cognitive Level: Comprehension
MSC: Client Needs: Physiologic Integrity
OBJ: Nursing Process: Planning
22. When caring for a child with an intravenous infusion, the nurse should include which
intervention in the plan of care?
a. Using a macrodropper to facilitate reaching the prescribed flow rate.
b. Avoid restraining the child to prevent undue emotional stress.
c. Changing the insertion site every 24 hours.
d. Observing the insertion site frequently for signs of infiltration.
ANS: D
The nursing responsibility for intravenous 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 intravenous
tubing in pediatrics. The intravenous site should be protected. This may require soft restraints
on the child. Insertion sites do notNURSINGTB.COM
need to be changed every 24 hours unless a problem is
found with the site. Frequent change exposes the child to significant trauma.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
23. It is important to make certain that sensory connectors and oximeters are compatible since
wiring that is incompatible increases the risk of which injury?
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,
not hyperthermia. 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
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
24. What intervention should the nurse implement when suctioning a child with a tracheostomy?
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
a. Encouraging the child to cough to raise the secretions before suctioning.
b. Selecting a catheter with a diameter three-fourths as large as the diameter of the
tracheostomy tube.
c. Ensuring that each pass of the suction catheter take no longer than 10 seconds.
d. Allowing the child to rest after every 5 times the suction catheter is passed.
ANS: C
Suctioning should require no longer than 10 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 child’s 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
DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
25. 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 NURSINGTB.COM
be increased or decreased without the practitioner being
informed because alterations in rate can cause hyperglycemia or hypoglycemia. Knowing this
will result in the infusion rate being set to the original prescribed flow rate.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
26. In preparing to give “enemas until clear” to a young child, the nurse should select which
solution?
a. Tap water
b. Normal saline
c. Oil retention
d. Fleet solution
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
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
27. What nursing action is appropriate for specimen collection?
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
a.
b.
c.
d.
Follow sterile technique for specimen collection.
Sterile gloves are worn if the nurse plans to touch the specimen.
Use Standard Precautions when handling body fluids.
Avoid wearing gloves in front of the child and family.
ANS: C
Standard Precautions should always be used when handling body fluids. Specimen collection
is not always a sterile procedure. Gloves should be worn if there is a chance the nurse will be
contaminated. The choice of sterile or clean gloves will vary according to the procedure or
specimen. The child and family should be educated in the purpose of glove use, including the
fact that gloves are used with every patient, so that they will not be offended or frightened.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
28. What information should the nurse include when teaching parents how to care for a child’s
gastrostomy tube at home?
a. Never turn the gastrostomy button.
b. Clean around the insertion site daily with soap and water.
c. Expect some leakage around the button.
d. Remove the tube for cleaning once a week.
ANS: B
The skin around the tube insertion site should be cleaned with soap and water once or twice
daily. The gastrostomy button should be rotated in a full circle during cleaning. Leakage
around the tube should be reported to the physician. A gastrostomy tube is placed surgically.
It is not removed for cleaning.
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PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
29. Which nursing action is the most appropriate when applying a face mask to a child prescribed
oxygen therapy?
a. Set the oxygen flow rate at less than 6 L/min.
b. Make sure the mask fits properly.
c. Keep the child warm.
d. Remove the mask for 5 minutes every hour.
ANS: B
A properly fitting face mask is essential for adequate oxygen delivery. The oxygen flow rate
should be greater than 6 L/min to prevent rebreathing of exhaled carbon dioxide. Oxygen
delivery through a face mask does not affect body temperature. A face mask used for oxygen
therapy is not routinely removed.
PTS: 1
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
30. What critical information should the nurse incorporate into care when using restraints on a
child?
a. Use the least restrictive type of restraint.
b. Tie knots securely so they cannot be untied easily.
c. Secure the ties to the mattress or side rails.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
d. Remove restraints every 4 hours to assess skin.
ANS: A
When restraints are necessary, the nurse should institute the least restrictive type of restraint.
Knots must be tied so that they can be easily undone for quick access to the child. The ties are
never tied to the mattress or side rails. They should be secured to a stable device, such as the
bed frame. Restraints are removed every 2 hours to allow for range of motion, position
changes, and assessment of skin integrity.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
31. 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 the 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. Even though these substances are
not nutritious, they can provide necessary fluid and calories and can be supplemented with
additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or
punishment.
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PTS: 1
DIF: Cognitive
Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
32. What procedure is recommended to facilitate a heelstick on an ill neonate to obtain a blood
sample?
a. Apply cool, moist compresses.
b. Apply a tourniquet to the ankle.
c. Elevate the foot for 5 minutes.
d. Wrap foot in a warm washcloth.
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
DIF: Cognitive Level: Application
OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
33. After collecting blood by venipuncture in the antecubital fossa, what intervention should the
nurse implement in order to assure control of any bleeding?
a. Keep arm extended while applying a bandage to the site.
b. Keep arm extended, and apply pressure to the site for a few minutes.
c. Apply a bandage to the site, and keep the arm flexed for 10 minutes.
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several
minutes.
ANS: B
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation.
Pressure should be applied before a bandage is applied.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential
34. 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
DIF: Cognitive Level: Comprehension
MSC: Client Needs: Physiologic Integrity
OBJ: Nursing Process: Planning
35. What nursing consideration is related to the administration of oxygen (O2) in an infant?
a. Humidify the oxygen if the infant can tolerate it.
b. Assess the infant to determine how much oxygen should be given.
c. Arterial oxygen saturation (SaO
2) readings are used to guide O2 therapy.
NURSINGTB.COM
d. Direct the oxygen flow so that it blows directly into the infant’s face in a hood.
ANS: C
Pulse oximetry is a continuous, noninvasive method of determining arterial oxygen saturation
(SaO2) to guide oxygen therapy. 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 infant’s face.
PTS: 1
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
36. When administering a gavage feeding to a school-age child, the nurse should implement what
intervention to assure safety?
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 the child on the right side after administering the feeding.
ANS: D
NURSINGTB.COM
MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
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
DIF: Cognitive Level: Application
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse is preparing for the admission of an infant who will have several procedures
performed. In which situation is informed consent required? (Select all that apply.)
a. Catheterized urine collection
b. Intravenous (IV) line insertion
c. Oxygen administration
d. Lumbar puncture
e. Bone marrow aspiration
ANS: D, E
Informed consent is required for invasive procedures that involve risk to a child, such as a
lumbar puncture, chest tube insertion, and bone marrow aspirations. Catheterized urine
collection, IV line insertion, and oxygen administration all fall under this category.
PTS: 1
DIF: Cognitive Level: Application
MSC: Client Needs: Safe and Effective
Care Environment
NURSINGTB.COM
OBJ: Nursing Process: Planning
2. The advantages of the ventrogluteal muscle as an injection site in young children include
which of the following? (Select all that apply.)
a. Less painful than vastus lateralis
b. Free of important nerves and vascular structures
c. Cannot be used when child reaches a weight of 20 lbs
d. Increased subcutaneous fat, which increases drug absorption
e. Easily identified by major landmarks
ANS: A, B, E
Less painful, free of important nerves and vascular structures, and easily identifiable are
advantages of the ventrogluteal muscle. The major disadvantage is lack of familiarity by
health professionals and controversy over whether the site can be used before weight bearing.
Cannot be used when a child is 20 lbs or more and increased subcutaneous fat are not
advantages of the ventrogluteal muscle as an injection site in young children.
PTS: 1
DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
COMPLETION
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MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
1. A child with congestive heart failure is placed on a maintenance dosage of digoxin. The
dosage is 0.07 mg/kg/day, and the child’s weight is 7.2 kg. The physician prescribes the
digoxin to be given once a day by mouth. Each dose will be _____ mg. Record your answer
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
DIF: Cognitive Level: Analysis
OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
MATCHING
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.
a. Lubricate the nasogastric tube with water-soluble lubricant.
b. Tape the nasogastric tube securely to the child’s 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 earlobe to the midpoint between
the xiphoid process and the umbilicus.
1.
2.
3.
4.
5.
6.
Step one
Step two
Step three
Step four
Step five
Step six
1. ANS:
OBJ:
NOT:
2. ANS:
OBJ:
NOT:
3. ANS:
OBJ:
NOT:
4. ANS:
OBJ:
NOT:
5. ANS:
OBJ:
NOT:
6. ANS:
OBJ:
NURSINGTB.COM
D
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
First step is the appropriate patient positioning.
F
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
Second step is to measure tube for appropriate insertion length.
A
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
Third step involves lubricating the tube in preparation for insertion to facilitate insertion.
E
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
Fourth step is the insertion of the tube
C
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
Fifth step the tube should be checked for correct placement to prevent aspiration.
B
PTS: 1
DIF: Cognitive Level: Application
Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
NURSINGTB.COM
MATERNAL CHILD NURSING CARE 6TH EDITION PERRY TEST BANK
NOT: Sixth step involves appropriate securing of the tube to the child’s face.
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