LIPPINCOTT QA REVIEW FOR NCLEX-RN PART 3

41. The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next: 1. Discontinue compressions but continue administering breaths with a bag-mask device. 2. Establish an intravenous line with a large bore needle while preparing the defibrillator. 3. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions. 4. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.

42. As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines that the teaching had been effective when a parent states: 1. “If I am by myself, I should call for help before starting CPR.”. 2. “I should compress the chest using 2 to 3 fingers.”. 3. “I should deliver chest compression at a rate of 100 per minute.”. 4. “If I can't get the breaths to make the chest rise, I should administer abdominal thrusts.”.

43. When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective?. 1. Mottling of the skin. 2. Pupillary dilation. 3. Palpable pulse. 4. Cool, dry skin.

44. A nurse walks into the room just as a 10-month-old infant places an object in his mouth and starts to choke. After opening the infant's mouth, which of the following should the nurse do next to clear the airway?. 1. Use blind finger sweeps. 2. Deliver back slaps and chest thrusts. 3. Apply four subdiaphragmatic abdominal thrusts. 4. Attempt to visualize the object.

45. When preparing to deliver back slaps to an infant who is choking on a foreign body, in which of the following positions should the nurse position the infant?. 1. Head down and lower than the trunk. 2. Head up and raised above the trunk. 3. Head to one side and even with the trunk lower than the head. 4. Head parallel to the nurse and supported at the buttocks.

46. A 6-month-old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a licensed practical nurse (LPN) administering CPR to an infant (see figure). To assist the LPN with CPR, the nurse should: 1. Take over rescue breaths with a rate of 1 breath per 5 compressions using a bag-mask device while the LPN continues compressions. 2. Take over compressions using one hand while the LPN uses a mask device to administer rescue breaths. 3. Take over rescue breaths using a rate of 2 breaths per 15 compressions using a bag-mask device while the LPN delivers compressions. 4. Take over compressions at 80 compressions a minute while the LPN uses a bag-mask device to administer rescue breaths.

47. When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, which of the following should the nurse tell the parents to use to deliver the blows?. 1. Palm of the hand. 2. Heel of the hand. 3. Fingertips. 4. Entire hand.

48. While the nurse is delivering abdominal thrusts to a 6-year-old who is choking on a foreign body, the child begins to cry. Which of the following should the nurse do next?. 1. Tap or gently shake the shoulders. 2. Deliver back slaps. 3. Perform a blind finger sweep of the mouth. 4. Observe the child closely.

49. A 3-year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first. 1. Draw blood cultures for complete blood count. 2. Start an intravenous line. 3. Inspect the child's throat with a tongue blade. 4. Maintain the child in an undisturbed, upright position.

50. The father of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the father do?. 1. Offer extra fluids frequently. 2. Bring the child to the clinic immediately. 3. Count the child's respiratory rate. 4. Use a hot air vaporizer.

51. A 21-month-old child admitted with the diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 bpm, and a temperature of 100.8°F (38.2°C) rectally. The nurse is having difficulty calming the child. Which of the following should the nurse do next?. 1. Administer acetaminophen (Tylenol). 2. Notify the primary care provider immediately. 3. Allow the toddler to continue to cry. 4. Offer clear fluids every few minutes.

52. A child has viral pharyngitis. The nurse should advise the parents to do which of the following? Select all that apply. 1. Use a cool mist vaporizer. 2. Offer a soft-to-liquid diet. 3. Administer amoxicillin. 4. Administer acetaminophen. 5. Place the child on secretion precautions.

53. A father brings his 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and “just doesn't seem to be acting right.” Which of the following actions should the nurse do first?. 1. Check the infant's heart rate. 2. Weigh the infant. 3. Assess the infant's oxygen saturation. 4. Obtain more information from the father.

54. While the nurse is working in a homeless shelter, assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which of the following actions would be most appropriate?. 1. Administer a nebulizer treatment. 2. Send the infant for a chest radiograph. 3. Refer the infant to the emergency department. 4. Provide teaching about cold care to the mother.

55. An infant is being treated at home for bronchiolitis. Which of the following should the nurse teach the parent about home care? Select all that apply. 1. Offering small amounts of fluids frequently. 2. Allowing the infant to sleep prone. 3. Calling the clinic if the infant vomits. 4. Writing down how much the infant drinks. 5. Performing chest physiotherapy every 4 hours. 6. Watching for difficulty breathing.

56. In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which of the following statements by the mother indicates successful teaching?. 1. “I need to be sure to take my child's temperature every day.”. 2. “I hope I don't get a cold from my child.”. 3. “Next time my child gets a cold I need to listen to the chest.”. 4. “I need to wash my hands more often.”.

57. The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first: 1. Position the child supine. 2. Call the rapid response team. 3. Offer the child a carbonated drink. 4. Place the child in a croup tent.

58. A teaching care plan to prevent the transmission of respiratory syncytial virus (RSV) should include which of the following? Select all that apply. 1. The virus can be spread by direct contact. 2. The virus can be spread by indirect contact. 3. Palivizumab (Synagis) is recommended to prevent RSV for all toddlers in day care. 4. The virus is typically contagious for 3 weeks. 5. Older children seldom spread RSV. 6. Frequent handwashing helps reduce the spread of RSV.

59. A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should most avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and: 1. An 18-month-old with RSV. 2. A 9-year-old 8 hours post-appendectomy. 3. A 1-year-old with a heart defect. 4. A 6-year-old with sickle cell crisis.

60. The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the IV has occluded. The nurse should: 1. Restart the IV. 2. Administer the medication intramuscularly. 3. Arrange for early discharge. 4. Contact the prescriber to request a prescription change.

61. A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. The charge nurse should tell the nurse: 1. “If you do not report the error, I will have to.”. 2. “Reporting the error helps to identify system problems to improve client safety.”. 3. “Notify the client's primary care provider to see if she wants this reported.”. 4. “This is not a serious mistake so reporting it will not affect your position.”.

62. A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The primary care provider is calling in a telephone prescription for ampicillin. The nurse should do which of the following? Select all that apply. 1. Ask the unit clerk to listen on the speaker phone with the nurse and write down the prescription. 2. Ask the primary care provider to come to the hospital and write the prescription on the chart. 3. Repeat the prescription to the primary care provider. 4. Ask the primary care provider to confirm that the prescription is correct as understood by the nurse. 5. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse.

63. The triage nurse in the emergency room must prioritize the children waiting to be seen. Which of the following children is in the greatest need of emergency medical treatment?. 1. A 6-year-old with a fever of 104°F (40°C), a muffled voice, no spontaneous cough, and drooling. 2. A 3-year-old with a fever of 100°F (37.8°C), a barky cough, and mild intercostal retractions. 3. A 4-year-old with a fever of 101°F (38.3°C), a hoarse cough, inspiratory stridor, and restlessness. 4. A 13-year-old with a fever of 104°F (40°C), chills, and a cough with thick yellow secretions.

64. A 6-month-old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for: 1. Starting oxygen. 2. Providing sedation. 3. Transferring to PICU. 4. Prescribing a chest CT scan.