rn nursing care of children 2019 with ngn
ati med surg proctored exam 2019
(ADHD) A nurse is providing teaching to the parents of a school aged child who has ADHD. Which of the following instructions should the nurse include?
Place the childs daily activities on an organizational chart
(Sickle cell) A nurse is caring for a child who has sickle cell anemia. Which of the following findings is
a priority for the nurse to report to the provider?
Facial twitching
(Tonsillectomy) A nurse in the PACU is caring for a school aged child immediately after a tonsillectomy. Which of the following actions should the nurse take?
Place the child in a side lying position
(STIs) A nurse in the ER is caring for an adolescent who was requesting testing for STIs. Which
of the following actions is appropriate for the nurse to take?
Obtain the written consent from the client
(Ferrous sulfate) A nurse is providing teaching about medication administration to the parents of the toddler who has a new prescription for liquid ferrous sulfate. Which of the following instructions should the nurse include?
Dilute the drops of water prior to administration
(Phenylketonuria) A nurse is providing dietary teaching to a parent of a 10-month-old infant who has
phenylketonuria. Which of the following responses by the parent indicates an understanding of the teaching?
I will steam carrots and will cut them into small pieces for her
(Appendectomy) a nurse is caring for a child who s 2 days post-op following an appendectomy due to the
rupture of the appendix the childs NG tube is set to low intermittent suction. Which of the following indicates that the childs GI function has returned?
. The nurse auscultates bowel sounds
(Diaper rash) A nurse is providing teaching to the parent of an infant who has a diaper rash. Which of
the following statements by the parents indicate an understanding of the teaching?
I will use superabsorbent disposable diapers
(Sickle cell crisis) a nurse is administering an opioid to an adolescent who is in a sickle cell crisis. Which statement is true regarding opioid pain management?
Oral opioid does should be larger than parenteral doses
(Shunt displaced) A nurse is providing discharge to the parents of a school aged child following placement
of a ventriculoperitoneal shunt. The nurse should determine the teaching was effective when the parents identify which of the following as an indicator that the shunt has been displaced?
Elevated temperature
(Labs) A nurse is reviewing laboratory results of a school aged child. Which of the following
findings to the nurse reports the provider?
Platelets 110,000
(Chest tube) A nurse is planning care for a child immediately following the insertion of a chest tube for continuous suction with a closed drainage system. Which of the following interventions should the nurse include in the plan of care?
Ensure continuous bubbling is present in the suction control chamber
(Digoxin) A nurses caring for an infant who has heart failure and is receiving digoxin. Which of the following findings indicates a positive response to the medication?
Urine output 2 mL/kg/hr
(RSV) A nurse is assessing a six month old infant who has respiratory syncytial virus. The nurse
should immediately report which of the following findings to the provider?
Tachypnea
(Newborn screen) A nurse is reviewing the results of the newborn screening of a newborn who is one week old. Results include total T4 0.8mcg/dl phenylalanine 0.7 and negative galactosemia. Which of the following nursing include in the plan of care?
nstruct the newborns parent about how to administer levothyroxine
(Diarrhea) A nurse is caring for a newly admitted toddler who has acute diarrhea. Which of the
following actions should the nurse take first.
Initiate contact precautions
(Cleft palate repair) A nurse is caring for toddler who post operative following cleft palate repair. Which of the following actions should the nurse take?
Administer opioids for mouth pain
(Measles) A nurse is assessing a child who has measles. Which of the following areas should the
nurse inspect for koplik spots?
Inside the mouth
(Otitis media) A nurse is assessing an infant who has acute otitis media which of the following findings should the nurse expect? Select all that apply.
a. Crying
b. Fever
c. Restlessness
(Gas inhalation) A nurse in the emergency department is assessing an adolescent who reports inhalation
of gasoline. Which of the fallowing should the nurse expect?
Ataxia
(Dehydration) A nurse caring for a 4 year old child who has moderate dehydration. Which of the fallowing should the nurse expect?
Orthostatic hypertension
(Lactose intolerance) A nurse is planning to teach an adolescent who is lactose intolerant about dietary
guidelines. Which of the fallowing instructions should the nurse include in the teaching?
You can replace milk with non dairy source of calcium
(Skeletal traction) A nurse is caring for a school age child who is in 90/90 skeletal traction. Which of the fallowing actions should the nurse take?
Place the child on an alternating pressure mattress
(Radiation therapy) A nurse is providing teaching to the parents of the child who is receiving radiation
therapy. Which of the fallowing instructions should the nurse include in the teaching? (select all that apply)
-Avoid giving your child lengthy baths
-Encourage mild activity daily
-Dress your child in loose fitting clothing
(Diabetes) A nurse is assessing a school age child who has type 1 diabetes mellitus. The nurse notes that the child is diaphoretic. Which of the following actions should the nurse take?
Obtain blood glucose level
(CF) A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new
prescription for dornase alfa. Which of the following instructions should the nurse include in the teaching?
store the medication in the refrigerator
(Gentamicin) A nurse is caring for a child who is to receive first dose IV gentamycin which of the
following actions should the nurse take?
Maintain strict I/O
(Immunizations) A nurse is preparing to administer immunizations to a 5 year old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
Varicella
(CF testing) A nurse is providing teaching to the parents of an infant who is to under go pilocarpine
iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include in the teaching?
Test will measure the amount of chloride in the babys sweat
(Terminal illness) A nurse is caring for a child who is terminally ill. The parents tell the nurse that the child
will be fine because they know another child who survived the same illness. Which of the following responses should the nurse make?
Tell me what you know about your childs illness
(Impetigo)A nurse is providing teaching to the parents of a child who has impetigo. Which of the
following instructions should the nurse include in the teaching?
Apply bacterial ointment to lesions
(Meningitis) A nurse is caring for a child who has bacterial meningitis, which of the following criteria should indicates the nurse should remove the child from droplet precautions?
antibiotics initiated 24 hour ago
(Assessment) A nurse is prioritizing care for four clients which of the following clients should the nurse
assess first?
An adolescent who has sickle cell anemia and slurred speech
(CF) A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect?
Steatorrhea
(Death response) nurses in a family practice clinic is assessing a preschool aged child who recently
experienced the death of a sibling. Which of the following reactions is an age appropriate response to death?
The child eels responsible to the childs death
(Vitals) A nurse in a providing office is assessing the vital signs of a 1 year old toddler which of
the following findings should the nursed report to the provider?
Respiratory rate 54
(Visual acuity) A nurse is preparing to assess a 4 year old child visual acuity. Which of the following actions should the nurse prepare to take?
Test the child without glasses before testing with
(HIv) A nurse is providing teaching to a parent of a child who has HIV. Which of the following
statement by the parent indicates an understanding of the teaching?
My child will need to repeat the childhood immunization once hes in remission
(Terminal illness) A nurse is caring for a preschool-age child who has a terminal illness. Which of the following should the nurse…
Believes the condition is permanent
(Sickle cell) A nurse is planning care for a child who was experiencing sickle cell crisis. Which of the
following interventions should the nurse have in plan of care?
Administer meperidine as needed for pain
(Arm cast) A nurse educating an adolescent following an application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?
I should limit the use of my fingers of my broken arm
(Immunizations) A nurse is providing teaching to a 2 month old infant about immunization schedules
which of the following statements from the parents indicate an understanding of the teaching?
My child needs to get the MMR immunization when she is 12 months old
(Safety) A nurse in providing injury prevention to the parents of the toddler which of the
following safety measures should the nurse incorporate in the teaching.
Check clothing for loose buttons
(ICp) indicates that the infant is experiencing ICP?
Irritability
(Assessment)A nurse in a urgent care clinic is prioritizing care for 4 children which of the children should the nurse asses first?
A toddler who has nephrotic syndrome and facial edema
(Asthma)a nurse in a emergency department is assessing a school age child who has asthma of
the following findings should the nurse prioritize?
Decrease breath sounds
(Diarrhea & dehydration) A nurse is providing to a parent to an 11 month old infant who has acute diarrhea ad dehydration what should the nurse instruct the parent to provide to the infant
oral electrolyte solution
(Immunization) A nurse is preparing to administer an immunization to a 3 month old infant which of the
following is relives atraumatic care?
Provide a pacifier coated with oral sucrose solution prior to the injections
(Osteomyelitis)A nurse is admitting a school age who has osteomyelitis which of the following actions…..
Obtain a blood culture
(Assessment) a nurse is assessing a 24 month toddler which of the finding should….?
Has a vocabulary of 40 words
(Seizures) a nurse is providing teaching to the parents of a school age child newly diagnosed with a
seizure disorder. The nurse should teach the parents which of the following actions during a seizure?
Clear the area of hard objects
(Immunization) A nurse is providing anticipatory guidance to a parents of a 1 month old infant. The
nurse should include that it is recommended to start the series of which of the following immunization first?
Inactivated poliovirus
(Glomerulonephritis) A nurse is providing education about dietary modifications to the parents of the school
age child who has glomerulonephritis. Which of the following information should the nurse include in the teaching?
Decrease the child sodium intake
(Diabetes) A nurse is assessing an adolescent who has type 1 diabetes mellitus which of the
fallowing findings is the nurse priority?
Glycosuria
(Hemolytic uremic shndrome) A nurse is reviewing the laboratory report of a toddler was has hemolytic uremic syndrome. Which lab values should the nurse expect?
BUN of 28
(Sickle cell) A nurse is caring for a school age child who is experiencing a sickle cell crisis. Which of
the following actions should the nurse take?
Apply warm compress to the infected joints
(Open heart surgery) A nurse on a pediatric intensive care unit is caring for a toddler who weighs 12kg and is postoperative following an open heart surgery. Which of the following findings should the nurse report to the provider?
Posterior and tibial pulse 2+
(Celiac disease) A nurse is providing teaching to the parents of a preschool age child who has celiac
disease. Which of the following instructions should the nurse include?
Your child will be on a gluten free diet for the rest of her life
(Tonsillectomy) A nurse is caring for a school age child who is 1 hour post op following a tonsillectomy. Which of the following actions should the nurse take
-Admin analgesics to the child on a schedule basis
-Observe the child for frequent swallowing
-And discourage coughing
(Asthma) A nurse admin albuterole by metered dose inhaler for a preschool aged child who is experiencing an asthma exacerbation. Which of the following should the nurse report to the provider?
Intercostal retractions
(Heart failure) A nurse is caring for a school age child who has heart failure. Which of the following
finding should the nurse expect?
-Tachycardia
-Cyanosis
-Dyspnea
-Bounding peripheral pulses
(Head injury) A nurse in the emergency department is assessing a toddler who has a head injury.
Which of the following findings should the nurse report to the provider?
Vomiting
(Neuroblastoma) A nurse is caring for a toddler who is terminal stage of neuroblastomas, the parent ask how can we help our child know which of the following responses by the nurse is appropriate?
Stay close to your child
(Well baby visit) During a well baby visit the parents of a 2 week old new born tells the nurse my baby
always keeps her head tilted to the right side. The nurse should further assess which of the following areas?
Sternocleidomastoid muscle
(Well baby visit) A nurse is caring for a single mother of a 6 month old infant. During a well baby visit the
mother expresses feelings inexperienced in care of the baby. The nurse should recommend which of the following community resource.
Parent enhancement center
(GERD) A nurse is admitting an infant who has GERD which of the following is priority
assessment finding?
Excessive crying
(Dehydration) A nurse is caring for an infant that has severe dehydration. Which clinical finding should the nurse expect?
Rapid respirations
(Healthy eating) A nurse is teaching a group of female adolescent about healthy eating. Which of the
following instructions should the nurse include in the teaching?
Consume 1500 to 1700 calories per day
(Cf) a nurse is providing discharge teaching to the parents of a school age child who has cystic fibrosis which response by the parents indicates an understanding if the teaching?
I will give my child pancreatic enzyme with snacks and meals
(Impetigo) A nurse is caring for a child who has impetigo contagiosa that developed in the hospital.
Which of the following actions should the nurse take?
Initiate contact isolation precaution
(Meningitis) A nurse is caring for a 4 year old child who has meningitis and is receiving gentamacin. Which of the following labs values should the nurse to the provider
Creatinine 1.4mg
(Adhd) A nurse is providing teaching to the parents of a school age child who has ADHD and a
new prescription of for methylphenidate. The nurse should explain that this medication should have which of the following therapeutic effects?
Increasing focus
(Cf) A nurse is teaching an adolescent how to manage his cystic fibrosis. Which of the
following statements by the adolescent indicates understanding of the teaching?
I will increase my intake of vitamin D
(Vein puncture) A nurse is preparing to perform a venipuncture to collect a blood sample from an infant which of the following restraints should the nurse plan to use for this procedure?
Mummy
(Epiglottis)A nurse in the providers office is caring for a preschool age child who might have a acute
epiglottitis which of the following actions should the nurse take?
provide humidifier oxygen via nasal cannula
(Rheumatic fever) A nurse is reviewing the laboratory report of A school age Child who has rheumatic fever which of the following laboratory findings should the nurse expect?
Increased antistreptolysin O titer
(Diverticulum)A nurse is planning care for adolescent follow repair of Meckel diverticulum which of the
following actions should the nurse include in the plan of care?
Maintain a NG tube for decompression
(Peritoneal dialysis) A nurses preparing to perform peritoneal dialysis for your child was elevated serum creatinine level after explaining the procedure which of the following action should the nurse plan to take?
Obtain child’s weight
(Appendectomy)A nurses caring for an adolescent who is one hour postoperative following
appendectomy which of the following findings should the nurse report to the provider?
Muscle rigidity
(Tonsillectomy) And nurses caring for preschool age child whose postoperative following a tonsillectomy and is clearing her throat frequently which of the following action should take first?
Give the child small sips of water
(Chemotherapy ulcers) And nurses planning care for a toddler who has developed oral ulcers in response to
chemotherapy which of the following actions should the nurse include in the plan of care?
Cleanse the gums with saline soaked gauze
(Chest tube insertion) In nurses planning care for the child immediately following her insertion of a chest tube
for continuous suctioned with a close drainage system which of the following intervention should the nurse include in the plan of care?
ensure continuous bubbling his present in the suction control chamber
(Cushings)a nurse is assessing an adolescent who has Cushing syndrome which of the following
findings should the nurse expect
blood glucose of 320
(FTT) A charge nurse is planning care for an infant who has failure to thrive which of the following actions should the nurse include in the plan of care?
Use half strength formula when feeding the infant
(Cardiac cath) A nurse is providing postoperative care for a child following an arterial cardiac
catheterization which of the following actions should the nurse take?
Keep affected extremity straight for about 6 hours
(SIDs) A nurses providing discharge teaching to the parents of an infant who is at risk for sudden infant death syndrome which of the following statements by the parents indicate an understanding of the teaching
I will dress my baby in light weight clothing to sleep
(Down’s syndrome) A nurse in the providers office is providing teaching to the parents of a preschooler who
has down syndrome which of the following statements buy one of the parents indicates an understanding of instructions?
We’ll be sure to demonstrate a new skill before expecting our Son to perform it.
(Safety) A nurse is teaching a parent of a 10 month old about home safety what should be
included in the teaching
-Place gates on top and bottom of stairs
-Ensure that the crib mattress is in the lowest position
(Diarrhea) A nurse is assessing a 3 month old infant who has diarrhea which of the following should
the nurse expect?
Increased hemocratic
(Umbilical hernia) A nurse is providing teaching to a parent of an infant who has 1 cm umbilical hernia which of the following instructions should the nurse include in the teaching
the bulge can temporarily enlarge when your baby cries
(Pertussis) A nurse is admitting for pertussis which transmission based precaution should the nurse
initiate
Droplet percussion
(Lead poisoning) In Nurse is assessing a toddler who has a history of lead poisoning which of the following actions should the nurse take?
Perform developmental testing for delays
(Physical abuse) A nurse is assessing a seven -year-old student the nurse should identify which of the
following finding as a potential indicator for physical abuse
Bruising around the wrist
(Leukemia) In nurses reviewing the medical record of a 24 month old child who has acute lymphocytic leukemia which of the following actions should the nurse take
Initiate bleeding precautions
(Iron def anemia) A nurses providing discharge teaching to the parents of a father who was iron deficiency
anemia and a new prescription for Ferrous sulfate which of the following instructions for the nurse include
Administer the medication to your child with the dropper
(Diabetes)Hey nurses providing teaching to the parent of the school’s child was diabetes mellitus
about managing diabetes during illness which of the following statements by the parents and the kids understanding of teaching?
I’ll increase them on the fluids offer to my child
(Tetralogy of fallot)A nurse is caring for an infant who has tetralogy of fallot and is having a hypercyanotic
episode after crying which of the following intervention should the nurse implement?
placed infant in knee chest position
(Pediculosis) A nurse is planning an inservice for parents of school age children about the tx of pediculosis cpaitis, which of the following instructions for the nurse to plan including in the teaching?
remove nits from child’s hair using a fine tooth comb
(Acetaminophen) A nurse in the emergency room is caring for a child who is 18 kg and injustice six
500 mg acetaminophen about four hours ago which of the following actions and there’s take?
Prepare to give oral N-acetylcysteine
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?
a. provide small, frequent meals for the child
b. schedule time in the play room for the child
c. weigh the child weekly
d. maintain the child in a supine position
A
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
a. “I should remove the harness at night to allow my infant to stretch her legs.”
b. “I will need to adjust the straps on the harness once a week.”
c. “I should apply baby powder to my infant’s skin twice daily.”
d. “I will place my infant’s diaper under the harness straps.”
D
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan?
a. administer ibuprofen to the child for a temperature greater than 38 degrees C (100.4 degrees F)
b. assess the child’s blood pressure every 8hr
c. weigh the child weekly at a various times of the day
d. initiate seizure precautions for the child
D
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
a. purulent nasogastric drainage
b. absence of peristalsis
c. passage of dark stool with mucus
d. WBC count 6000mm^3
B
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
a. place a cardiac monitor on the adolescent prior to the procedure
b. apply topical analgesic cream to the site 1hr prior to the procedure
c. keep the adolescent in a semi-fowler’s position for 4hrs following the procedure
d. restrict fluids for 2hrs following procedure
B
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
a. prednisone
b. epinephrine
c. diphenhydramine
d. albuterol
B
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
a. “I will use a humidifier in my child’s room at night.”
b. “I will give my child a cough suppressant Q6hrs if he has a cough.”
c. “I should avoid using a wet mop on my floors when I am cleaning.”
d. “I house keep my child indoors when I mow the yard.”
D
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
a. wheat crackers
b. rye bread
c. barley soup
d. white rice
D
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
a. hematocrit 28%
b. hemoglobin 13.5 g/dL
c. WBC count 8000mm^3
d. platelets 250000/mm^3
A
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take?
a. obtain a sputum specimen
b. perform an Allen test
c. perform a finger stick
d. obtain a stool specimen
C
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
a. reports a headache as 6 on a 0-10 pain scale
b. petechiae on the lower extremities
c. nuchal rigidity
d. positive Kernig’s sign
B
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
a. loud, hard murmur
b. dysrhythmias
c. weak femoral pulses
d. high BP
A
A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury. Which of the following interventions should the nurse include in the plan?
a. position the infant side-lying with their head at a )-5 degree angle
b. perform a neurological assessment Q4hrs
c. suction the infant’s nares to remove secretions
d. implement seizure precautions for the infant
D
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
a. negative leukocyte esterase
b. serum creatinine 3.0 mg/dL
c. negative urine protein
d. urine output 40ml/hr
B
A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider?
a. excoriated scrotal area
b. multiple capillary hemangiomas
c. depressed posterior fontanel
d. substernal retractions
D
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler’s parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?
a. “it is important that you provide emotional support for your family at this time.”
b. “You have to do what you feel is best. Everything will turn out fine.”
c. “I know how you feel. This is an extremely stressful time for your family.”
d. “Let’s talk about some of the ways you have handled previous stressors in your life.”
D
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
a. hgb 8.5g/dL
b. WBC 9500/mm^3
c. prealbumin 18mg/dL
d. platelets 300000/mm^3
A
A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, “Who should sign my surgical consent?” Which of the following responses should the nurse make?
a. “You can sign the consent form because you are married”
b. “Your spouse should sign the consent form for you.”
c. “Your parent should sign the consent form for you”
d. “You can appoint a legal guardian to sign the consent form.”
A
A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?
a. identifies right from left hand
b. uses a utensil to spread butter
c. cuts an outlined shape using scissors
d. draws a stick figure with seven body parts
C
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control?
a. have a designated stethoscope in the infant’s room.
b. place the infant in a room equipped with negative airflow
c. administer palivizumab as prescribed for the infant
d. remove gloves after leaving the infant’s room
A
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take?
a. instill a 500ml tap water enema
b. give morphine 0.05mg/kg IV
c. administer polyethylene glycol 1g/kg PO
d. apply a heating pad to the child’s abdomen
B
A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock?
a. blood pressure 130/90 mm Hg
b. HR 60/min
c. Temp 39.1 Degrees C (102.4 Degrees F)
d. urinary output 100ml/hr
C
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
a. expresses a reluctance to leave home
b. provides a detailed description of how the burns occurred
c. denies discomfort during assessment of injuries
d. describes strong relationship with peers
C
A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
a. sodium 148 mEq/L
b. urine specific gravity 1.020
c. mental confusion
d. weak peripheral pulses
C
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply)
a. negative Babinski reflex
b. ankle clonus
c. exaggerated stretch reflexes
d. uncontrollable movements of the face
e. contractures
B, C, E
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
a. increase anterior convexity of the lumbar spine
b. increased curvature of the thoracic spine
c. lateral flexion of the neck
d. a unilateral rib hump
D
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
a. “your daddy will back at 7pm.”
b. “Your daddy will be back after he takes care of your brother.”
c. “Your daddy will be back in the morning”
d. “Your daddy will be back after you eat.”
D
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order of performance)
a. remove the tape securing the catheter
b. occlude the IV tubing
c. Turn off the IV pump
d. apply pressure over the catheter insertion site
C, B, A, D
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
a. place the child in a side-laying position
b. delay documentation until the child is fully alert
c. give the child a high-carb snack
d. administer an oral sedative to the child
A
A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
a. “I should secure the car seat using lower anchors and tethers instead of the seat belt.”
b. “I should position the car seat harness 1″ above my baby’s shoulders.”
c. “I will make sure that the car seat is placed at a 90 degree angle.”
d. “I will pad my baby’s car seat with a blanket for traveling long distances”
A
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
a. inflamed throat with exudate
b. purulent eye drainage
c. dry, hacking cough
d. kolpik spots on a buccal mucosa
C
A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take?
a. place the child in a prone position for the immunization
b. request that the child’s caregiver leave the room during the immunization
c. administer the immunization using a 24 gauge needle
d. inject the immunization slowly after aspiration for 3 seconds
C
A nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?
a. occupational therapist
b. speech therapist
c. respiratory therapist
d. physical therapist
B
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
a. laryngeal edema
b. flank pain
c. distended neck veins
d. muscular weakness
B
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take?
a. insert a nasogastric tube
b. initiate prophylactic antibiotic use
c. cleanse the affected area with mild soap and water
d. apply a topical corticosteroid to the affected area
C
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?
a. decreased cerebrospinal fluid pressure
b. decreased WBC count
c. increased protein concentration
d. increased glucose level
C
A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
a. BP 90/50
b. RR 45
c weight 14.5 kg (32lbs)
d. HR 110
B
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching?
a. “My child will have a cast until healing is complete.”
b. “My child will receive antibiotics for several weeks.”
c. “My child can return to playing sports once they have been discharged.”
d. “My child needs to be in contact isolation.”
B
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
a. playing pat-a-cake
b. using a push-pull toy
c. creating a scrapbook
d. playing dress-up
D
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
a. potassium 2.9 mEq/l
b. sodium 140 mEq/L
c. urine specific gravity 1.035
d. BUN 25 mg/dL
B
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
a. apply topical antimicrobial ointment to the child’s wound.
b. place a mesh gauze dressing over the child’s wound
c. administer an analgesic to the child
d. initiate prophylactic antibiotic therapy for the child
C
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?
a. recurrent urinary tract infections
b. symmetric burns of the lower extremities
c. failure to thrive
d. lack of subcutaneous fat
B
A nurse is caring for a school-age child who is in Buck’s traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take?
a. change the child’s position every 2hrs
b. clean the peripheral pin sites with chlorhexidine solution every 4 days
c. assess peripheral pulses once every 4 hours
d. ensure that the head of the bed is elevated to a 90 degree angle
C
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
a. instruct the parents to decrease the calcium in their toddler’s diet
b. prepare the toddler for chelation therapy
c. refer the family to child protective services
d. schedule the toddler for a yearly rescreening
D
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?
a. a school age child who has sickle cell anemia and reports decreased vision in the left eye
b. a school age child who has cystic fibrosis and a frequent nonproductive cough
c. a preschooler who has asthma and a peak flow meter reading in the green zone
d. an adolescent who has meningitis and reports a sensitivity to lights and noise
A
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area.
a. zinc oxide
b. antibiotic ointment
c. talcum powder
d. antiseptic solution
A
A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
a. use surgical asepsis when providing routine care for the child
b. administer the measles, mumps, and rubella (MMR) vaccine to the child
c. screen the child’s visitors for indications of infection
d. infuse packed RBCs
C
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
a. skin breakdown
b. hypotension
c. hyperpyrexia
d. tachypnea
D
A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
a. “I will puncture the pad of my finger when I am testing my blood glucose.”
b. “I will give myself a shot of regular insulin 30 minutes before I eat breakfast.”
c. “I will eat a snack of 5 grams of carbohydrates if my blood glucose is low.”
d. “I will decrease the amount of fluids I drink when I am sick.”
B
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?
a. “Place the infant in a prone position to sleep.”
b. “Allow the infant to sleep on a large pillow.”
c. “Use a soft mattress in the infant’s crib.”
d. “Give the infant a pacifier at bedtime.”
D
A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect?
a. hyperactive bowel sounds
b. abdominal distention
c. bradycardia
d. bloody stool
B
A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
a. the toddler has a vocabulary of 25 words
b. The toddler developed a mild rash following a recent varicella immunization
c. the toddler’s Moro reflex is absent
d. the toddler received tobramycin during a hospitalization 2 weeks ago
D
A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?
a. “Shake the medication prior to administration.”
b. “Provide the medication through a straw.”
c. “Rinse the child’s mouth with water immediately after giving the medication.”
d. “Mix the medication with applesauce if the child dislikes the taste.”
A
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?
a. place the child in a room with a positive pressure airflow
b. place the child in a room with a negative pressure airflow
c. initiate contact precautions for the child
d. initiate droplet precautions for the child
D
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
a. apple juice
b. peanut butter
c. chicken broth
d. oral rehydration solution
D
A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
a. elevate the head of the child’s bed
b. insert a large bore IV catheter for a child
c. determine the allergen that caused the child’s reaction
d. administer epinephrine IM to the child
D
- A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?
a. provide small, frequent meals for the child - A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
d. “I will place my infant’s diaper under the harness straps.” - A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan?
d. initiate seizure precautions for the child - A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
d. tachypnea - A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
b. absence of peristalsisc - A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?
b. “I will give myself a shot of regular insulin 30 minutes before I eat breakfast.” - A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
B. apply topical analgesic cream to the site 1hr prior to the procedure - A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
b. epinephrine - A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
d. “I house keep my child indoors when I mow the yard.” - A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?
d. white rice - A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
a. hematocrit 28% - A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take?
c. perform a finger stick - A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
b. petechiae on the lower extremities - A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
a. loud, hard murmur - A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?
d. “Give the infant a pacifier at bedtime.” - A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect?
b. abdominal distention - A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
d. the toddler received tobramycin during a hospitalization 2 weeks ago - A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?
A. “Shake the medication prior to administration. - A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?
d. initiate droplet precautions for the child - A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler
d. oral rehydration solution - A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
d. administer epinephrine IM to the child - A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?
c. denies discomfort during assessment of injuries - A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury. Which of the following interventions should the nurse include in the plan?
d. implement seizure precautions for the infant - A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
b. serum creatinine 3.0 mg/dL - A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply)
b. ankle clonus
c. exaggerated stretch reflexes
e. contractures - A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider?
d. substernal retractions - A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler’s parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?
d. “Let’s talk about some of the ways you have handled previous stressors in your life.” - A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
a. hgb 8.5g/dL - A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, “Who should sign my surgical consent?” Which of the following responses should the nurse make?
a. “You can sign the consent form because you are married - A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?
c. cuts an outlined shape using scissors - A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control?
a. have a designated stethoscope in the infant’s room. - A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take?
b. give morphine 0.05mg/kg IV - A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock?
c. Temp 39.1 Degrees C (102.4 Degrees F) - A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
c. mental confusion - A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
d. a unilateral rib hump - A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
d. “Your daddy will be back after you eat.” - A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order of performance)
c. Turn off the IV pump
b. occlude the IV tubing
a. remove the tape securing the catheter
d. apply pressure over the catheter insertion site - A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
a. place the child in a side-laying position - A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
a. “I should secure the car seat using lower anchors and tethers instead of the seat belt.” - A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
c. dry, hacking cough - A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take?
c. administer the immunization using a 24 gauge needle - A nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair. For which of the following members of the inter-professional team should the nurse initiate a referral?
b. speech therapist - A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
b. flank pain - A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take?
c. cleanse the affected area with mild soap and water - A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?
c. increased protein concentration - A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
b. RR 45 - A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching?
b. “My child will receive antibiotics for several weeks. - A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
d. playing dress-up - A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
b. sodium 140 mEq/L - A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
c. administer an analgesic to the child
42A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?
b. symmetric burns of the lower extremities
- A nurse is caring for a school-age child who is in Buck’s traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take?
c. assess peripheral pulses once every 4 hours - A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
d. schedule the toddler for a yearly rescreening - A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?
a. a school age child who has sickle cell anemia and reports decreased vision in the left eye - A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?
a. zinc oxide - A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
c. screen the child’s visitors for indications of infection
A nurse is assessing a school-age child who has heart failure and is taking furosemide.
Which of the following findings should the nurse identify as an indication that the medication
is effective?
a. An increase in venous pressure
b. a decrease in peripheral edema
c. a decrease in cardiac output
d. an increase in potassium levels
b
A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect (SATA)
A. Increased appetite
B. Enlarged subclavian lymph nodes
C. Crying
D. Restlessness
E. Fever
CDE
A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine lontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include in the teaching?
A. We will measure the amount of protein in your baby’s urine over a 24 hour period.
B. The test will measure the amount of water in your baby’s sweat.
C. A nurse will insert an IV prior to the test
D. Your baby will need to fast for 8 hours prior to the test
B
A nurse in an urgent care clinic is prioritizing care for children. Which of the following children should the nurse assess first?
A. A toddler who has nephrotic syndrome and facial edema
B. A preschool age child who has a muffled voice and no spontaneous cough
C. A preschool age child who has diabetes mellitus and a blood glucose of 200 mg/dL
D. An adolescent who has Crohn’s disease and a recent weight loss of 5 kg mg (11 lb)
B
A nurse is providing teaching to the parents of a toddler who is to undergo a sweat chloride test. Which of the following statements should the nurse include?
A. The purpose of the test is to determine if your child has Crohn’s disease
B. The technician will use a device to produce an electrical current during the test.
C. During the test your child will be in a room that is cold
D. Your child’s sweat will be collected over 24 hours
D
A nurse in the emergency department is caring for an adolescent who is requesting testing for an STI. Which of the following action is appropriate for the nurse to take?
A. Request verbal consent from the social worker
B. Contact the patients parents to obtain phone consent
C. Postpone the testing until the patients parents are present.
D. Obtain written consent from the patient
D
A nurse in the emergency department is assessing the toddler who has hyperpyrexia severe dyspnea and drooling which of the following actions should the nurse take first?
A. Obtain a blood culture from the toddler
B. Administering antibiotics to the toddler
C. Insert an IV catheter for the toddler
D. Prepare the toddler for nasotracheal intubation
D
A nurse is providing teaching to a 10 year old child scheduled for an arterial cardiac catheterization. Which of the following information should the nurse include in the teaching?
A. You will have your dressing removed 12 hours after the procedure
B. You will need to keep your legs straight for 8 hours following the procedure
C. You will be on a clear liquid diet for 24 hours following the procedure
D. You will be on bed rest for 2 days after the procedure
B
A nurse is caring for a preschooler who is post operative following a tonsillectomy. The child is now ready to resume oral intake which of the following dietary choices should the nurse offer the child?
A. Sugar free cherry gelatin
B. Vanilla ice cream
C. Chocolate milk
D. Lime flavored ice pop
D
A nurse is caring for an infant who has patent ductus arteriosus. The nurse should identify that the defect is a switch of the following locations of the heart.
B
A nurse is caring for a 10 month old child who was brought to the ER by his parents following a head injury. Which of the following actions should the nurse take first?
A. Inspect for fluid leaking from the ears
B. Asses respiratory status
C. Check pupil reactions
D. Examine the scalp for lacerations
B
A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?
A. Assign consistent nursing staff care for the infant
B. Keep the infant in a visually stimulating environment
C. Use half strength formula when feeding the infant
D. Give the infant fruit juice between feedings
A
A nurse is providing teaching about home care to the parent of a child who has scabies. Which of the following instructions should the nurse include in the teaching?
A. Wash your patients hair with shampoo containing Ketoconazole
B. Soak combs and brushes in boiling water for 10 minutes
C. Apply petroleum jelly to the affected areas
D. Treat everyone who came into close contact with the child
D
A nurse is caring for a preschooler who refuses to take a start dose of oral diphenhydramine. Which of the following statements should the nurse make?
A. The medication isn’t bad it tastes like candy
B. Let me know when you want to take the medication
C. The medication will treat your hypersensitivity reaction
D. Sometimes when a child has to take medications they feel sad
D
A nurse is teaching the parent of a school age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?
A. Your child should walk the bicycle through intersections
B. Your child’s feet should be 3-6 inches off the ground when seated on the bicycle
C. You should try to keep the bicycle at least 3 feet from the curb while riding in the street
D. Your child should ride the bicycle against the flow of traffic
A
A nurse is caring for a school age child following the application of a cast to a fractured right tibia. Which of the following actions should the nurse take first?
A. Teach the child about cast care
B. Pad the edges of the cast
C. Administer pain medication
D. Elevate the child’s leg
B
A nurse is preparing a school age child for an invasive procedure. Which of the following actions should the nurse plan to take?
A. Plan for 30 minute teaching session about the procedure
B. Use vague language to describe the procedure
C. Explain the procedure to the child when they are in the playroom
D. Demonstrate deep breathing and counting exercises
C
A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following actions should the nurse take?
A. Apply lidocaine gel to the perineum before attaching the bag
B. Position the opening of the bag over the urethra and the anus
C. Stretch the perineum taut when applying the bag
D. Place a snug fitting diaper over the drainage bag
C
A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care?
A. Schedule routine oral care every 8 hours
B. Cleanse the gums with saline soaked gauze
C. More sending me closer with lemon glycerin swabs
D. Administer oral viscous lidocaine
B
A nurse is providing discharge teaching to the parents of an infant who is at risk for SIDS. Which of the following statements by the parent indicates an understanding of the teaching?
A. I will have my baby sleep next to me in the bed during the night
B. Elmo my baby stuffed animal to the corner of her crib while she sleeps
C. I will dress my baby in lightweight clothing to sleep
D. I will lay my baby on her side to sleep for her naps
C
A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
A. Increase BP
B. Limb withdrawal
C. Relaxed facial expressions
D. Bradycardia
C
A nurse is caring for a 3 month old infant who has cleft of the soft palate. Which of the following actions should the nurse take?
A. Discontinue feeding if the patients eyes become watery
B. Postpone burping the infant until after completing each feeding
C. Elevate the infants head to a 10 degree angle during feedings.
D. Feed the infant 177.4 ml (6 oz) of formula 3 times a day.
A
A nurse is caring for a child who has hyponatremia. Which of the following findings should the nurse expect?
A. Tetany
B. Weight gain
C. Elevated heart rate
D. Excessive diaphoresis
A
A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube. Which of the following actions should the nurse take first?
A. Set the administration rate on the feeding pump
B. Flush the tube with water
C. Check the pH of the gastric secretions
D. Attach the feeding bag tubing to the end of the NG tube.
C
A nurse is caring for an adolescent who is 1 hour postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
A. Temperature of 36.4 c
B. Muscle rigidity
C. Heart rate 64/min
D. Abdominal pain
B
A nurse is a providers office is preparing a administer immunizations to a 12 year old client during a well child visit. Which of the following immunizations should the nurse plan to administer?
A. DTaP
B. Human papillomavirus HPV
C. Varicella
D. Hepatitis A
B
A nurse is planning care for an 8 month old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?
A. Provide less frequent, higher volume feedings
B. Repeat a digoxin dosage if the infant vomits within 1 hour of administration
C. Place the infant in a prone position
D. Administer a cool humidified oxygen via nasal cannula
D
A nurse is planning care for a school aged child who was admitted from the ER 2 hours ago. Which of the following interventions should the nurse include to promote adequate sleep for the child?
A. Provide the child with video games prior to bedtime to reduce stress
B. Follow the child’s home sleep routine to reduce anxiety
C. Leave the lights on in the child’s room to promote safety
D. Allow the child to adjust their bedtime to promote autonomy
B
A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month old infant. Which of the following actions should the nurse plan to take?
A. Start the IV in the infants foot
B. Change the IV site every 3 days
C. Use a 24 gauge catheter to start the IV
D. Cover the insertion site with an opaque dressing
D
A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestations should the nurse include as an indication of digoxin toxicity?
A. Diaphoresis
B. Bradycardia
C. Polyuria
D. Jaundice
B
A nurse is reviewing laboratory results of a child who was recently admitted for a suspected rheumatic fever. The nurse should identify which of the following laboratory tests can contribute to confirming the diagnosis? (SATA)
A. Partial thromboplastin (PIT)
B. Erythrocyte sedimentation rate (ESR)
C. C reactive protein (CRP)
D. Antistrepolysin O (ASO) titer
E. Blood urea nitrogen (BUN)
BCD
A nurse is teaching a group of female adolescents about healthy eating. Which of the following instructions should the nurse include in the teaching?
A. Limit your sodium intake to 3,000 mg per day
B. Consume 1500 to 1700 calories per day
C. Decrease your vitamin D intake once you start to menstruate
D. Increase the amount of your dietary iron intake
D
A nurse is caring for an infant who receives intermittent enteral feedings through a gastronomy tube. Which of the following actions should the nurse take when administering a feeding? (SATA)
A. Instill the formula over a period of 30-45 minutes
B. Hear the formula to 39 C prior to administration
C. Check for residual volume by aspiration stomach contents
D. Place the infant in supine position
E. Offer the infant a pacifier during feedings
ACE
A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care?
A. Provide a high calorie low protein diet
B. Maintain a patent IV catheter
C. Encourage frequent physical activity to increase bone mass
D. Initiate contact precautions for the child
B
A nurse is providing teaching to the guardians of a school age child who has sickle cell disease about the management of the illness. Which of the following instructions should the nurse include?
A. Limit fluids at bedtime
B. Have the child wear a surgical mask to school
C. Apply cold compress to painful areas
D. Encourage physical activity as tolerated
D
A nurse is assessing a 5 month old infant. Which of the following findings should the nurse report to the provider?
A. Unable to hold s bottle
B. Unable to roll from back to abdomen
C. Exhibits head lag pull to sitting position
D. Absent grasp reflex
C
A nurse is caring for a 5 year old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
A. Heart rate 54/min
B. Continuous swallowing
C. Flushing of the face
D. Blood pressure 95/56
B
A nurse is discussing coping mechanisms with a parent of a 3 months old infant. Which of the following therapeutic questions should the nurse ask the parent.?
A. Does parenting cause you stress
B. Are you willing to take new parenting classes
C. What do you do when your infant is having a bad day
D. Is it overwhelming when your infant is having a bad day?
C
A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. Which of the following responses by the parents indicates an understanding of the teaching?
A. My child should remain under a beach umbrella during morning hours
B. I should dress my child in loose wear clothing
C. I should apply 10 spf sunscreen to my child’s entire body
D. My child should wear a wide brimmed hat
D
A nurse is evaluating a 4 year old child who has cystic fibrosis and has been receiving chest physiotherapy treatments. The nurse should identify which of the following findings as an indication that the therapy has been effective ?
A. Reduced pain
B. Increased urine output
C. Increased expectoration
D. Increase heart rate
C
A nurse is planning care for a 6 month old infant who has bacterial meningitis. Which of the following interventions should the nurse include in the plan of care?
A. Provide frequent ROM to the neck and shoulders
B. Keep the TV on in the room to provide background noise
C. Place the infant in a semiprivate room
D. Pad the side rails of the crib
D
A nurse is providing the medical record of a school age child who has cystic fibrosis. Which of the following findings should the nurse report to the provider?
A. Heart rate
B. WBC count
C. Oxygen saturation
D. HbA1c
D
A nurse is assessing an infant who has severe dehydration due to gastroenteritis which
of the following findings should the nurse expect?
a. Increased respiratory rate
b. capillary refill of 2 seconds
c. Hypertension
d. increased urine output
A
A nurse is assessing an infant who has intussusception. Which of the following findings
should the nurse expect?
a. sausage-shaped abdominal Mass
b. board like abdomen
c. Constipation
d. increased urinary output
A
A nurse is caring for a 14 year old adolescent who has a cast on the right arm and
swelling of their right hand. The nurse elevates The Adolescents affected extremity. The nurse
should identify that which of the following findings is an indication that the intervention has
been effective?
a. The Adolescent reports of the cast feels tight
b. The Adolescents hands feel cool to touch
c. the Adolescent is able to move their fingers freely
d. the Adolescent reports feeling tingling in their arms
C
A nurse in a provider’s office is assessing the vital signs of a two-year-old child at a
well-child visit. Which of the following findings should the nurse report to the provider?
a. Respiratory rate 26 / min
b. pulse rate 98 / minutes
c. temperature 37.2 Celsius (99 Fahrenheit)
d. blood pressure 118 / 74 mmhg
D
A nurse is preparing to administer a prescribed medication to a toddler whose parent
is nearby. Which of the following actions should the nurse take to identify the toddler?
a. check the toddler’s room number against their ID band
b. check the toddler’s ID band against the medical record
c. ask the parent to confirm the toddler’s identity
d. ask another nurse to confirm to toddlers identity
B
A nurse is teaching home care to the parents of a preschool-age child who has heart
failure. Which of the following information should the nurse include in the teaching?
a. Weight the child once each month month
b. withhold digoxin of the child’s pulse is greater than 100 / minutes
c. provide for periods of rest
d. increase the child’s oxygen flow rate until the child no longer has cyanosis
C
A nurse in the PACU is caring for a school-age child immediately following a
tonsillectomy. Which of the following actions should the nurse take?
a. Place the child in a side-lying position
b. offer the child ice cream when alert
c. instruct a child to drink fluids through a straw
d. encourage the child to deep breathe and cough
A
A nurse is reviewing the medical record of a 15 month old child who is scheduled to
receive measles, mumps, rubella. Which of the following findings Should the nurse
identify as a contradiction for receiving the vaccine?
a. upper respiratory
b. allergy to neomycin
c. temperature of 37.2 (99 Fahrenheit)
d. family history of seizures
B
A nurse is assessing a school-age child cranial nerve function. Which of the
following actions should the nurse ask the child to take when assessing the
accessory nerve?
a. Move their tongue in all directions
b. follow a light in the six cardinal position
c. shrug their shoulders against mild pressure
d. show their teeth while smiling
C
A nurse is performing a cranial nerve assessment on a school-age child. Which of
the following findings indicates proper function of the child trigeminal nerve?
a. The child montanes balance when standing with eyes closed
b. the child correctly identify specific scent
c. the child has asymmetrical jaw strength when Biting Down
d. the child exhibits a gag reflex when stimulated with a tongue blade
C
A nurse is providing support to a family whose infant died from sudden infant
death syndrome (Sid’s) which of the following actions should the nurse take?
a. Discourage the parents from allowing siblings to view the body
b. avoid discussing details of the attempt to revive the infant
c. provide a follow-up phone call one week following the infant’s death
d. acknowledge the family members feelings of guilt
D
A nurse in the emergency department is caring for a child who has a temperature of
39.1 degrees C is (102.4 Fahrenheit) and suspect the diagnosis of bacterial meningitis.
Which of the following actions should the nurse take first? Tell me more
a. prepare the child for a lumbar puncture
b. dim the lights in the child’s room (SEIZURE PRECAUTION)
c. administering an antipyretic to the child
d. Implement droplet precautions for the child
D
A nurse is caring for an infant who has rotavirus. Which of the following findings
indicates that the infant is moderately dehydrated?
a. capillary refill 1 seconds
b. weight loss 7% lower
c. Respiratory rate 28/ minute
d. bradycardia
B
A nurse is providing teaching to the guardian of a school-age child who has seizure
disorder. Which of the following factors should the nurse include as a common trigger that
increases the risk of seizure?
a. Prolonged headache
b. decrease temperature
c. lack of sleep
d. exposure to second-hand smoke
C
A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and
notes the clients potassium level is 3.2 meq L which of the following assessment findings
should the nurse expect?
a. Hypertension
b. Hyporeflexia
c. hyperactive bowel sounds
d. Oliguria
C OR D
A nurse is planning care for an adolescent who has sickle cell anemia. Which
of the following immunizations should the nurse include in the plan?
a. Respiratory sync functional virus (RSV to call)
b. Rotavirus
c. measles, mumps, and rubella (MMR)
d. pneumococcal conjugate (pcv13)
D
A nurse is planning care for a child who has varicella. Which of the following
interventions should the nurse plan to include?
a. Initiate Airborne precaution
b. assess the oral cavity for koplik spots
c. administer aspirin for fever
d. provide the child with a warm blanket
A
A nurse is planning care for a school-age child who has a new diagnosis of Legg calve
perthes disease. Which of the following interventions should the nurse include in the plan
of care?
a. instruct a child to perform weight bearing exercises
b. explain to the child that the disease will last 3 to 6 months
c. encourage the guardian to keep their child home from school for one
month
d. administer ibuprofen to the child for discomfort
D
A nurse is caring for a two-year-old child who has cystic fibrosis and is being discharged
from the hospital. The nurse should ensure that which of the following pieces of equipment
is available for the child’s home?
a. steam vaporizer
b. suction machine
c. continuous positive airway pressure machine
d. high frequency chest compression vest
D
A nurse is providing teaching for the parent of a child who has measles. Which of
the following information should the nurse include?
a. Bathe the child using tepid water
b. remove loose crust from the lesions
c. give the child aspirin for a fever
d. withhold live vaccines for 3 months
D
A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings
should the nurse expect?
a. Steatorrhea
b. Rhinorrhea
c. weight gain
d. visible peristalsis
A
A nurse is providing teaching to the parents of a child who has impetigo. Which
of the following instructions should the nurse include in the teaching?
a. Apply bactericidal ointment to lesions
b. Soak hair brushes in boiling water for 10 min
c. Administer acyclovir PO two times per day
d. Seal soft toys in a plastic bag for 14 days
A
A school nurse is assessing a 7-year-old student. The nurse should
identify which of the following findings is a potential indicator of physical
abuse?
a. Abrasions on the knees.
b. Front deciduous teeth missing.
c. Weight in 45th percentile.
d. Bruising around the wrists.
D
A nurse is caring for a school-age child following the application of a cast to a
fractured right tibia. Which of the following actions should the nurse take first?
a. Teach the child about cast care
b. Petal the edges of the cast
c. Administer pain medication
d. Elevate the child’s leg
b
A nurse is preparing to administer immunizations to a 3-month-old infant. Which
of the following is an appropriate action for the nurse to take to deliver atraumatic care?
a. Provide a pacifier coated with an oral sucrose solution prior to the injections
b. Use a 20-gauge needle for the injections
c. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before
the injections
d. Inject the immunizations into the deltoid muscle.
A
A nurse is providing teaching to the parents of a 2-month old infant who has
developmental dysplasia of the hip and has a prescription for a Pavlik harness. Which of the
following statements by the parents indicates an understanding of the teaching?
a. “We should adjust the straps daily”
b. “We will apply lotion to the skin under the straps”
c. “We will place the diaper under the straps”
d. “We should expect our baby to wear this harness for 2 weeks”
C
A nurse in an emergency department is caring for a preschool-age child who has
acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?
a. Jaundice
b. Hyperpyrexia
c. Polyuria
d. Neck vein distention
B or A
A nurse is admitting a child who has acute epiglottitis. Which of the following
actions should the nurse take?
a. Initiate droplet isolation precautions
b. Obtain a throat culture
c. Assist the child into supine position
d. Check oxygen saturation every 4 hr.
A
A nurse is providing teaching to the guardians of a school-age child who has sickle
cell disease about the management of the illness. Which of the following instructions
should the nurse include?
a. limit fluids at bedtime
B. have the child wear a surgical mask to school
c. apply cold compress to painful areas
D. encourage
physical activity as tolerated
D
A nurse is caring for a 4-year old child who has meningitis gentamicin. Which of
the following laboratory values should the nurse report to the provider?
a. BUN 6 mg/dL
b. Creatinine 0.3 mg/dL
c. BUN 12 mg/dL
d. Creatinine 1.4 mg/dL
D
A nurse is assessing a 6-month old infant who has respiratory syntactical virus.
The nurse should immediately report which of the following findings to the provider?
a. Rhinorrhea
b. Tachypnea
c. Pharyngitis
d. Coughing
B
A nurse is prioritizing care for four clients. Which of the following clients should
the nurse assess first?
a. A toddler who has a partial thickness burn on his right hand and requires a dressing
change
b. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
c. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus
of nafcillin
d. An adolescent who has sickle cell anemia and slurred speech
D
A nurse is providing teaching to the parents of a school-age child newly diagnoses
with a seizure disorder. The nurse should teach the parents to take which of the following
actions during a seizure?
a. Insert a tongue blade between the
teeth
b. Clear the area of hard objects
c. Place the child in prone position
d. Minimize movements of the limbs
B
A nurse is planning to teach an adolescent who is lactose intolerant about dietary
guidelines. Which of the following instructions should the nurse include in the teaching?
a. You should consume flavored yogurt instead of plain
yogurt
b. You can replace milk with nondairy sources of
calcium
c. You might tolerate plain milk better than chocolate milk
d. You can drink milk on an empty stomach
B
A nurse in an emergency department is assessing an adolescent who
reports inhalation of gasoline. Which of the following findings should the nurse
expect?
a. Hyperactive reflexes
b. Pinpoint pupils
c. Hypothermia
d. Ataxia
D
A nurse is creating a plan for an adolescent who has muscular dystrophy. Which of the
following interventions should the nurse include in the plan?
a) Encourage the adolescent to perform incentive spirometry to maintain lung capacity.
b) Recommend the adolescent use of a wheelchair to prevent stress on the lower
extremities
c) Initiate a referral for chest physiotherapy every 4 H
d) Avoid influenza and pneumococcal vaccines for 24 months
A
A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an
appropriate action for the nurse to take?
a. Clean around the stoma with full-strength hydrogen peroxide
b. Use clean technique to change the tracheostomy
tube
c. Have the child flex his head while securing the
tube
D. Place the child in a trendelenburg position while performing care
C
A nurse is caring for a child who received partial thickness burns to over 50% of his
body 10 days ago and has splints over his joints to prevent contractures. Which of the
following actions should the nurse take? (select all)
A.Monitor intake and output
B.Administer analgesics IM
C.Remove splints during sleep
D.Provide a high calorie diet
E.Change dressing using aseptic technique
ADE
A nurse is planning to administer immunizations to a 2-month-old infant. Which of
the following actions should the nurse take to decrease the nurse’s pain?
A. administer the injections while the infant is breastfeeding
B. apply a warm pack to the injection site prior to administration
C. ask the parent to leave the room during injections
D. administer the injections in the deltoid muscle
A
A nurse is teaching about growth and development to a parent of a 12 year old child.
The nurse should instruct the parent to expect the child to exhibit which of the
following characteristic during an early adolescence?
a. Mood swings
b. Emotional separation from parents
c. Increased self-esteem
d. Decelerating growth rate
A
A nurse in the emergency department is caring for a school-age child who has
developed respiratory stridor, wheezing, and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?
A. administer epinephrine
B. administer a nebulized bronchodilator
C. administer oxygen
D. Administer methylprednisolone
A
A nurse in an emergency department is caring for a child who experienced a
submersion injury. Which of the following is the priority action for the nurse to take?
a. Assist with intubation
b. Obtain an ABG sample
c. Administer an IV bolus
d. Apply warming blankets
A
A nurse is assessing a toddler who has a history of lead poisoning. Which of
the following actions should the nurse take?
a. Obtain a stool specimen for lead levels
b. Initiate a low-iron diet for lead absorption – increase calcium and iron for prevention of
lead poisoning
c. Perform developmental testing for delays
d. Inspect the skin for discoloration
C
A nurse is caring for a school-age child who is experiencing a sickle-cell crisis. Which of
the following actions should the nurse take?
a. Initiate contact precautions
b. Decrease The Child’s Fluid Intake
c. Administer furosemide IV twice per day
d. Apply Warm Compress The Affected Areas
D
A nurse is assessing a child who has multiple closed fractures of the lower
extremities due to a motor-vehicle crash. The nurse should monitor the child for which
of the following complications during the first 24 H after the injury occurred?
a. Renal Calculi
b. Compartment Syndrome
c. Osteomyelitis
D. Volkmann Ischemic contracture
B
- A nurse is assessing a 6 month old infant who has respiratory syncytial virus. The
nurse should immediately report which of the following findings to the provider?
A. Rhinorrhea
B. Pharyngitis
C. Tachypnea
D. Coughing
C
A nurse is caring for a school-age child who is 1 hour postoperative following
a tonsillectomy. Which of the following actions should the nurse take? (SATA)
a. Observe The Child For Frequent Swallowing
b. Maintain The Child In A Supine Position
C. administer an analgesic to the child on a scheduled
basis
D. Discourage the child from coughing
e. Provide Cranberry Juice The Child
ACD
- A nurse is teaching the guardian of a 5-year-old child who has encopresis about
management of the condition. Which of the following statements by the
guardian indicates an understanding of the teaching?
a. I will have my child sit on the toilet for 20 minutes at a time
b. I Will Limit My Child’s Fluid Intake
c. I will increase my child’s dairy intake
d. I will take my child to defecate 15 minutes after each meal
D
A nurse is communicating with a child who has hearing loss. Which of the
following actions should the nurse take?
A. Use light touch when initiating
conversation
B. Exaggerate the pronunciation
of words
C. Maintain a neutral facial expression when speaking
D. Change positions frequently to maintain attention
A
A nurse is teaching a group of parents about childhood immunizations. The nurse
should identify that infants should receive the first dose of which of the following
immunizations at 12 months of age?
a. Varicella
b. Human papillomavirus
c. Hepatitis B
d. IPV inactivated poliovirus
A
A nurse is teaching the parent of a toddler who has phenylketonuria about meal
planning. Which of the following information should the nurse include in the
teaching?
a. Increase The Toddler’s Protein Consumption
b. Avoid Consuming Milk Products
c. Limit foods high in iron
d. Use Aspartame As Sugar Substitute
B
A nurse is reviewing the medical record of a 24 month old child who has
acute lymphocytic leukemia. Which of the following actions should the nurse
take?
A. Initiate bleeding precautions
B. Apply viscous lidocaine to the oral mucosa
C. Obtain a rectal temperature every 4 hours
D. Place the child in knee chest position
A
A nurse is caring for a 2 month old infant who has Heart Failure & is receiving furosemide.
Which of the following findings is the nurse’s priority?
A. Sunken anterior fontanel
B. Negative doll’s eye reflex
C. HR 162
D. Potassium 5.1
A
A Nurse is teaching a parent of a 10-month old infant about home safety. Which of the
following should the nurse include in the teaching? SATA
A. Remove labels from containers that contain toxic substances
B. Place gates at the top & bottom of the stairs
C. Ensure the crib mattress is in the lowest position
D. keep toilet lids upright
BC
A Nurse is assessing a 24 month old toddler. Which of the following findings should the
nurse report in the provider?
A. Eats a large amount of food one day then very little the next
B. Has a vocabulary of 30 words
C. Sleeps 11-12 hr per day
D. Hold his breath when having a temper tantrum
B
A Nurse is collecting data from a toddler who weighs 20kg (44lb) & has a full-
thickness burn to 10% of this body. Which of the following findings should the nurse
report to the provider?
A. Increased restlessness
B. Respiratory rate 25 min
C. Bowel sounds 20/min
D. Urinary output 35 ml/hr
A
A nurse is teaching a parent about home interventions for a preschooler who is
experiencing night terrors. Which of the following instructions should the nurse include
in the teachings?
- Wake your child up during the night terror
- Allow your child to watch an animated movie right before bedtime
- Avoid allowing your child to sleep in your bed
- Wait until your child indicates that he is tired before putting him into bed.
C
A nurse is preparing to administer lidocaine and prilocaine cream to a child prior to the
insertion of an IV catheter. Which of the following actions should the nurse plan to take?
-Wash the site with alcohol prior to applying the cream
- apply the cream 1 hr before the procedure
-gently rub the cream into the skin - avoid removing the cream prior to the procedure
B
A nurse is assessing a toddler who is 8H postoperative following a cardiac
catheterization procedure. Which of the following findings should the nurse report to the
provider?
- Serum glucose 90mg/dl
- Blood pressure 102/58
- Weak pulse distal
-bilateral cool extremities
D
A nurse in a community clinic is reviewing the laboratory results of four clients. The
nurse identified which of the following sexually transmitted infections is nationally notifiable?
a. Herpes simplex virus
b. Human Papillomavirus
c. Gonorrhea
d. Bacterial vaginosis trichomoniasis
C
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is
the priority for the nurse to report to the provider?
- Nightmares
- Pruritis
- Diplopia
- Hyperactivity
C
A nurse is planning care for an adolescent following repair of Meckel diverticulum. Which
of the following actions should the nurse include in the plan of care?
a. Initiate long-term antibiotic therapy
b. Administer total parenteral nutrition
c. Teach the client about ostomy care
d. Maintain an NG tube for decompression
D
A nurse is planning to admit a preschooler from the PACU following removal of a Wilms
tumor. Which of the following children should the nurse assign as an appropriate roommate for
the preschooler?
a. A child who has a fractured left femur
b. A child who has cellulitis of the right radius
c. A child who has impetigo
d. A child who has viral pneumonia
A
A nurse is caring for a school-age child who has pertussis. Which of the following
actions should the nurse take?
- Report the diagnosis to the public health department
- Restrict oral fluids to 500 mL per day
- Place the child in a protected environment for 48 hr
- Administer the pertussis vaccine
A
A nurse at an inpatient facility is planning care for a child who has autism spectrum
disorder. Which of the following interventions should the nurse include in the plan of care?
- Keep Staff visits with the child brief
- Allow the child a semiprivative room
- Keep TV on in childs room for background noise
- Vary daily routine when providing care for the child
A
A nurse is providing teaching to a parent of a child who has HIV. Which of the following
statements by the parent indicate an understanding of the teaching?
- My child will need to repeat his childhood immunizations once he is remission
- My child will need to double his medication for the next six months
- The risk of transmission decrease once my child is on zidovudine for 2 weeks
- I will ensure that my child is tested for tuberculosis every year
D OR A
A nurse is teaching a group of male adolescents about testicular self examination which
of the following statement should the nurse include in the teaching
- Perform the examination following a warm shower
- You shold perform the examination once every other month
- You should notify your provider if your tests are firm and egg shaped
- If you feel a hard lump wait 1 month and retest yourself
A
A nurse is caring for an adolescent who has major depressive disorder which of
the following actions should the nurse take firsts
- Ask the client if he is considering harming himself
- Assist the client in completing his ADLs
- Administer an antidepressant to his client
- Encourage the client to attend a group therapy session
A
A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following
finding requires requires immediate intervention by the nurse?
- Dark brown blood noted in emesis
- Child reports pain level of 5 on the FACES scale
- Frequent swallowing
- Axillary temperature 38 C (100 F)
C
A charge nurse is teaching a roup of nurses about identifying child abuse. Which of
the following findings should identify as an indicator of child abuse?
- An 8 month old infant cries when his parent leaves the room
- A toddler repeatedly refuses to let a nurse auscultate his lungs
- A mother is hesitant to comfort her 6 month old infant
- A toddler has bruises on his knees.
B
A nurse is educating an adolescent following the application of an arm cast. Which of
the following statements by the client indicates understanding of the teaching?
- I should limit the use of the fingers of my broken arm
- I will sprinkle baby powder into the cast if my arm itches
- I will elevate my broken arm on pillows at night
- I should expect my fingers to be swollen for several days.
A or c
A nurse is providing teaching to the parent of a child who has varicella about
management of the disease. Which of the following instruction should the nurse include in the
teaching
- Keep child away from other s until the skin is clear of scabs
- Apply calamine lotion to vesicles on the child’s skin
- Dress the child in warm clothing to promote healing of vesicles
- Avoid giving the child a bath while vesicles are present.
B
A nurse is preparing to perform a venipuncture to collect a blood sample from an
infant. Which of the following restraints should the nurse use for the procedure?
a. Elbow
b.Mummy
c. Mitten
d. Jacket
B
A nurse is caring for a group of clients. Which of the following findings should the
nurse report to the provider?
a. Infant who has a respiratory rate of 30
b. An adolescent who has BP of
132/82
c. Toddler who has a heart rate
of 68
d. School-age child who has a rectal body temp of 37.3 C
C
A nurse is planning care for a child who is experiencing a sickle cell crisis. Which of
the following interventions should the nurse include in the plan of care?
a. Administer Meperidine As Needed For
Pain
b. Initiate Bedrest
c. Apply cold compress to affected joints
d. Limit Fluid Intake
B
- A nurse is creating a plan of care for a toddler who is recovering following a routine
surgical procedure. Which of the following interventions should the nurse include?
a. Use Cooling Blanket On The Toddler
b. Administer aspirin to the toddler as Needed For Pain
c. Administer IV dexamethasone/dantrolene sodium to the
toddler
d. Encourage The Toddler To Use An Incentive
Spirometer
D
A nurse is teaching the parent of a toddler about administering digoxin. Which of
the following statements by the parents indicates an understanding of the teaching?
a. I should give my child another dose if he vomits right after taking the
medication
b. I Should Give My Child Water After Giving The Medication
c. I should mix the medication with 4 ounces of my of my child’s favorite juice
D. I should give the medication with food that are high in fiber
B
A nurse is caring for a child who has bacterial meningitis. Which of the following
findings should indicate to the nurse that the child can be removed from droplet
precautions.
a. Negative Cerebrospinal Fluid Culture
b. Temperature below 37.4C
c. Antibiotics initiated 24 Hr ago
d. Absent nuchal rigidity
C
A nurse is assessing a client who has Hodgkin’s lymphoma. Which of the following findings
should the nurse expect?
a. Flushed Skin
b. Decreased Body Temperature
c. Unexplained weight gain
D. Night sweats
D
A nurse is caring for a client who is postoperative following placement of a halo vest to
manage a cervical vertebral fracture. Which of the following actions should the nurse take?
a. Assess the pin sites for infection once every other day
b. Encourage Flexion And Extension Of The Neck
c. Reposition the client using a turning sheet
d. Tighten the screws on the halo device one quarter turn every 48 hour
C
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following
findings is the nurse’s priority?
a. Cholesterol 189 Mg/dl
b. Glycosuria
c. Preprandial blood glucose 124 mg/dl
d.HBA1C 11.5%
D
A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an
appropriate action for the nurse to take?
a. Clean Around The Stoma With Full-strength hydrogen peroxide
b. Use Clean Technique To Change The Tracheostomy Tube
c. Have the child flex his head while securing the tube
d. Place the child in trendelenburg position while performing care
C
A nurse is preparing a child for a lumbar puncture. In which of the following positions should the
child be placed for the procedure?
-semi flower
-supine
-lateral
-prone
C
A nurse is reviewing the complete blood count for a child who is receiving
treatment for acute lymphoblastic leukemia. Which of the following should
indicate that the treatment is having a therapeutic effect?
a. RBC count 5/mm
b. Platelet count 98,000
c. Hemoglobin 6.8
d. WBC count 15,000
A
A nurse is teaching an adolescent client about the complication and effects of
cigarette smoking. Which of the following techniques should the nurse include
when teaching the client?
a. Make the adolescent participate in a detailed discussion using
simple terminology to explain why they should quit smoking
b. Encourage the adolescent to participate in a role-playing activity
about the long-term effects of cigarette smoking
c. Provide an active discussion about the effects of cigarette smoking
will have on their skin and overall appearance
d. Ask the adolescent to draw a picture of the lungs before and after
prolonged cigarette smoking
C
A nurse is planning care for a child who has a prescription to transfuse 2
units of packed RBCs. Which of the following interventions should the include in
the plan of care?
a. Infuse each unit of blood within 4 hrs
b. Store the second unit of blood at room temperature for up to 2 hr
c. Administer RBCs using non-filtered IV tubing
d. Infuse dextrose 5% in water during the infusion of packed RBCs
A
A nurse is educating an adolescent following the application of an arm cast.
Which of the following statements by the client indicates an understanding of the
teaching?
a. I should limit the use of the fingers of my broken arm
b. I will baby powder into the cast if my arm itches
c. I should expect my fingers to be swollen for several days
d. I will elevate my broken arm on pillows at night
A
A nurse is caring for an infant who has pneumonia and a temperature of 38.9
Which of the following actions should the nurse take?
a. Check the infant’s temperature 30 minutes after administering antipyretic
b. Give the infant a sponge bath using tepid water
c. Chill the surface of the infant’s skin by placing ice packs at the groin axilla
d. Administer acetaminophen every 2 Hr until the infant’s temperature is
within the expected reference range
A
A nurse in a family practice is assessing a preschool-age child who recently
experienced the death of a sibling. Which of the following reactions is an age
appropriate response to death?
a. The child feels responsible for the sibling’s death
b. The child is curious about what happened to the sibling’s body
c. The child can give a logical explanation for the sibling’s death
A
A nurse is caring for a child who has bacterial meningitis. Which of the following
findings should indicate to the nurse that the child can be removed from droplet
precautions.
a. Negative cerebrospinal fluid culture
b. Temperature below 37.4 C
c. Antibiotics initiated 24 Hr ago
d. Absent nuchal rigidity
C
A nurse is teaching the parents of a 4-month old infant about expected milestones
during the first year of life. Which of the following information should the nurse include in
the teaching? (SATA)
a. The infant should kneel without support at 12 months
b. The infant should roll from back to abdomen at 6 months
c. The infant should sit without support at 8 months
d. The infant should use a palmar grasp at 5 months
e. The infant should crawl at 7 months
BCD
A nurse in an emergency department is caring for a child who experienced a
submersion injury. Which of the following is the priority action for the nurse to take?
a. Assist with intubation
b. Obtain an ABG sample
c. Administer an IV bolus
d. Apply warming blankets
A
A nurse is assessing four children. For which of the following children should the
nurse recommend a referral to a speech therapist?
a. A 3-year-old preschooler who has a history of a cleft palate repair
b. A 4-year-old preschooler who stutters when beginning a sentence
c. A 2-year-old toddler who has acute otitis media
d. A 1-year-old infant who knows 3-5 words
A
A nurse is providing discharge teaching to the guardian of a child who has cystic
fibrosis. Which of the following statements by the guardian indicates an understanding
of the teaching?
a. I will expect my child to need annual sweat chlorine testing
b. I will ensure that my child consumes a high calorie diet
c. I will have my child take the pancrealipase medication before eating
d. I will administer dornase alpha every 4 hrs for wheezing
B
A nurse is caring for a school-age child who is 1 hour postoperative following a
tonsillectomy. Which of the following actions should the nurse take? (SATA)
a. Observe the child for frequent swallowing
b. Maintain the child in a supine position
c. Administer an analgesic to the child on a scheduled basis
d. Discourage the child from coughing
e. Provide cranberry juice to the child
ACD
- A nurse is caring for a child who is terminally ill. The parents tell the nurse, “Our
child will be fine. After all, we have heard of other children who have survived the
same illness.” Which of the following responses should the nurse take?
a. “Tell me what you know about your child’s illness”
b. “The provider told you that your child’s illness is terminal”
c. “Let’s talk about some happy memories with your child”
d. “It is important that you believe your child will survive”
A
A nurse is teaching the parent of a toddler who has phenylketonuria about meal
planning. Which of the following information should the nurse include in the
teaching?
a. Increase the toddler’s protein consumption
b. Avoid consuming milk
products
c. Limit foods high in
iron
d. Use aspartame as a sugar substitute
C
A nurse is teaching home care to the parents of a preschool age child who has
heart failure. Which of the following information should the nurse include in the
teaching?
provide for periods of rest
A nurse is completing an admission assessment on an adolescent child who is a
vegetarian. He eats milk products but does not like beans. Which of the following items
should the nurse suggest the client order for lunch to provide nutrients most likely to be lacking in his diet?
A. Peanut butter and jelly sandwich
B. Baked potato topped with sour cream
C. Bagel with cream cheese
D. Fruit salad
A
A nurse is preforming a precollege assessment on an adolescent. Which of the following
immunizations should the nurse anticipate administering?
Meningococcal polysaccharide vaccine
A nurse is assessing a client who has left sided hear failure. Which of the following
findings should the nurse expect?
weak peripheral pulses; dependent edema
A nurse is caring for a client who has active TB and is to be started on IV rifampin
therapy. The nurse should instruct the client that this medication can cause which of the
following adverse effects
body secretions turning a red orange color
A nurse is providing education to the parent of a child who has cystic fibrosis
and has a prolapsed rectum. The nurse should teach that which of the
following is a cause of this complication:
a. Bulky stools
b. Weakened rectal sphincter
c. Elevated pancreatic enzymes
d. Decreased intra abdominal pressure
A
A pre-schooler is admitted to the emergency department with full thickness
third degree burn over 45% of his body. Which of the following actions should
the nurse take first:
a. Administer IV morphine
b. Administer IV antibiotics
c. Administer IV solutions
d. Administer total parenteral nutrition
C
A nurse is providing teaching to a parent of a pre-schooler who has Tinea
Capitis. Which of the following should the nurse include in the teaching:
a. Apply 1 to 20 burrow’s solution compressed to the lesions
b. Apply hydrocortisone cream to the lesions twice daily
c. Seal and wash toys in plastic bag for two weeks
d. Leave the shampoo on the scalp for 5 to 10 minutes
D
A nurse is caring for a child who has sickle cell anemia. Which of the following
signs of acute chest syndrome should the nurse report to the primary care
provide immediately:
a. Congestive cough
b. Dilute hearing
c. Hct of 10g/dl
d. Systolic murmur
A
A nurse is assessing a 3month old infant for suspected intussusception. Which
of the following findings should the nurse expect:
a. Jelly-like stool
b. Board-like abdomen
c. Projectile vomiting
d. Oliguria
A
A nurse is planning a teaching session for parents regarding infant
development. Which of the following parent activities regarding play should
the nurse include in the teaching:
a. Encourage the infant in one on one play
b. Promote play with other infants
c. Provide visual stimulation with pastel colored toys
d. Give the infant a large piece puzzle
A
A school-aged child with sickle cell anemia has been admitted in vaso-
occlusive crisis. Which of the following assessment findings should the nurse
recognize as an emergency?
a. Slurred speech
b. Fever of 38.30 C (1010 F)
c. Hematuria
d. Pain level of 7 on a faces scale
A
A nurse in an emergency department is assessing a child who was in a motor
vehicle accident. Which of the following assessment findings require
immediate intervention:
a. Dilated and fixed pupils
b. Disorientation to person and place
c. Positive Babinski reflex
d. Restless and irritable
A
A nurse is assessing a child who has sustained a head injury. During the
assessment, the nurse observes clear drainage leaking from the child’s nose.
Which of the following actions should the nurse take?
a. Perform naso-tracheal suctioning
b. Test the nasal secretions for glucose
c. Maintain direct lighting on the child
d. Lower the head of the bed
B
A nurse at a provider’s office is preparing a newborn for a routine heel
puncture. Which of the following actions should the nurse take?
a. Administer tolectin (tolmetin) prior to the procedure
b. Apply EMLA cream to the heel after the procedure
c. Prepare concentrated sucrose for oral administration
d. Place the new born in an extended position
C
A nurse is caring for a child who has rheumatic fever. Which of the following is
an indication that the child has developed carditis?
a. Carotid bruit
b. Chest pain
c. Hypotension
d. Cyanosis
B
A parent calls the clinic asking for pinworm testing information, the nurse
should advise the parent to perform the test at which of the following times?
a. Immediately after child has a bowel movement
b. After being on a clear diet for 24hrs
c. Immediately after the child awakes in the morning
d. After soaking for 20 minutes in a warm bath
C
A nurse is educating the parents of an infant who has mild gastroesophageal
reflux. Which dietary adjustment should the nurse recommend?
a. Provide a little sprout formula
b. Administer nasogastric feedings
c. Thicken feedings with rice cereal
d. Place infant in a lateral position for one hour after feedings
C
A nurse is teaching an adolescent client about managing asthma and using a
peak respiratory flow meter. Which of the following by the client
demonstrates an understanding of the teaching:
a. I will use my peak flow meter whenever I feel short of breath
b. I will continue to take my medication when my peak flow meter is
in the green zone
c. I need to use the average of three readings when I measure my flow
rate
d. My asthma is being controlled if my flow rate is in the yellow zone
B
A nurse is instructing the parent of an infant who has clubfeet and has cast
applied. Which of the following statements by the parent indicates a need for
further teaching:
a. My baby will need to return to have his cast changed weekly
b. I need to check my baby’s toes for any discolorations daily
c. My baby will need to have surgery at 18 months if his toes aren’t
fixed
d. I will check the skin around my baby’s cast at every diaper change.
C
A nurse assesses an infant that is admitted for acute gastroenteritis. Which of
the following is the priority finding?
a. Decreased tears
b. Capillary refill of 5 seconds
c. Heart rate 150/min
d. Dry mucous membranes
C
A nurse is planning to teach a nutrition class for preschoolers. Which of the
following is an appropriate instructional strategy? (Select all that apply.)
a. Offer written handouts
b. Limit the teaching session to 45 minutes
c. Use simple language
d. Incorporate games into the lesson
e. Provide concrete examples
BCDE
A nurse is caring for a toddler who has a fever, high-pitched cry, irritability and
vomiting. Which of the following is an appropriate action for the nurse to
take?
a. Administer 81mg of Aspirin
b. Place the toddler in a cold water bath
c. Place the toddler in a supine position
d. Pad the rails of the bed
d
A nurse is reviewing the morning lab results for an infant who is receiving
Digoxin and Lasix for the treatment of heart failure. Which of the following
should the nurse report to the provider:
a. Sodium 140 mEq/L
b. Calcium 10.2 mg/dL
c. Chloride 100 mEq/L
d. Potassium 3.2 mEq/L
D
A nurse is caring for a school aged child who has an arm cast applied 8 hours
ago. Which of the following findings should alert the nurse of complications
related to the casting:
a. Child rates pain of 5 on a scale from 0 to 10
b. Child’s hands are cool bilaterally
c. Child reports tightness at the wrist
d. Child grasp is weak
C
A nurse is performing a neurological examination on a 15-month-old child.
Which of the following is an expected normal finding?
a. Negative Babinski reflex
b. Presence of Moro reflex
c. Absence of corneal reflexes
d. Positive palmar grasp
A
Which of the following actions indicates to the nurse that the parent of a
preschooler is using an age-appropriate disciplinary technique?
a. Explains to the child why her behavior is unacceptable ?
b. Places the child in time out after misbehaving
c. Allows the child to choose the consequence for her misbehavior
d. Assigns an extra chore for the misbehavior
A
A nurse is caring for an infant who is pre-operative for the treatment of mild
myelomeningocele. In which of the following positions should the nurse place
the infant:
a. Side-lying
b. Supine
c. Prone
d. Semi-Fowlers
C
A nurse is providing postoperative care for an infant who has pyloric stenosis.
Which of the following actions should the nurse take?
a. Use a re-breather mask to provide oxygen
b. Place the infant in a supine position
c. Initiate feedings with clear fluids
d. Weigh the infant every 48 hours
C
A nurse is admitting a child with tonic clonic seizures. Which of the following
is the priority to have in the room:
a. Pulse ox meter
b. Oxygen therapy
c. Valve mask
d. Suction equipment
D
An infant has had a cardiac catheterization with a right femoral entry to
diagnose a possible congenital heart defect. Following this procedure, the
nurse should be concerned about which of the following:
a. Cool toes on the right foot
b. Weak pedal pulses on both feet
c. Positive Babinski on both feet
d. Erythema on the right foot
A
A nurse is developing a health program for the parents of school age females.
Which of the following regarding sexual maturation should the nurse include:
a. Higher body fat content is often highly associated with earlier onset of
menarche
b. Pubic hair is typically present prior to breast development
c. Ovulation begins after sexual maturation is complete
d. Menarche signals the beginning of puberty
A
A nurse is assessing a child who has measles (rubella). Which of the following
findings should the nurse expect?
a. Vesicular rash
b. Koplik spots
c. Para oximal
d. Sternal retractions
B
On the way to the emergency department a parents reports a child
accidentally ingested overdose acetaminophen. Which of the following
medications should the nurse prepare to administer?
a. Naloxone
b. Diphenhydramine
c. Glucagon
d. Acetylcysteine
D
A nurse preceptor is working with a newly licensed nurse in caring for a child
that is postoperative for a placement of a tracheaosophageal shunt. Which of
the following statements made by the newly licensed nurse indicates a need of
further teaching:
a. I will ensure that pressure is not applied to the shunt valve
b. I will pump the shunt every two hours
c. I will keep the head of the bed flat for two hours
d. I will offer prescribed pain medication as needed
A
A nurse is teaching the parents of a toddler who has a new prescription for an
oral iron supplement. Which of the following should the nurse recommend for
administration with the medication to increase its absorption:
a. A protein source
b. Orange juice
c. Milk
d. A whole grain fiber
B
A nurse is evaluating the anticipatory grieving of a parent do to the impending
loss of a child. Which response indicates a need for further assessment by the
nurse:
a. “We will encourage our other children to be involved in the care of our
child.”
b. “We have contacted hospice to ensure our child does not have pain.”
c. “We understand our child will be most comfortable in a hospital.”
d. “We have given our child permission to die.”
C
A nurse is assessing an adolescent female. The adolescent’s mother tells the
nurse she is concerned that her daughter is too thin. Which of the following
assessment findings are consistent with anorexia nervosa?
a. Hyperactive deep tendon reflexes
b. Lanugo over the back
c. Oily skin with acne
d. Elevated body temperature
B
A nurse is educating the family of a child regarding hospice care. Which of the
following should the nurse include in the teaching:
a. “The hospice staff will be the primary care giver of this child.”
b. “Hospice staff consider the needs of the family as important as
those of this child.”
c. “Hospice care will end with the death of the child.”
d. “The priority of hospice care is to provide curative treatment for the
child.”
B
A nurse is caring for a breast-feeding infant who is given amoxicillin for an
upper respiratory infection. Assessment of the mouth reveals white patches
that would not scrape off. Which of the following nursing interventions is
appropriate?
a. Offer the infant water before feedings
b. Discontinue the amoxicillin
c. Administer antifungal medication after feedings
d. Give the infant formula instead of breast milk
C
A nurse is caring for a child who has acute renal failure. Which of the following
findings is of priority concern to the nurse?
a. Hyperphosphatemia
b. Hyponatremia
c. Hypocalcemia
d. Hyperkalemia
D
A nurse is caring for an infant admitted with hydrocephalus, and increased
intracranial pressure. Which of the following findings should the nurse
expect?
a. Decreased occipital frontal circumference
b. A depressed fontanel
c. Unresponsive to physical stimuli
d. A high-pitched cry
D
A nurse is caring for a toddler who is postoperative following the repair of a
cleft palate. Which of the following interventions by the nurse is appropriate?
a. Restrain arms at the elbows
b. Feed with a spoon
c. Monitor oral temperature
d. Provide pacifier for comfort
A
A parent of an infant who is taking Digoxin (Lanoxin) phones the nurse at a
clinic because the child has vomited the medication. Which of the following is
the priority nursing intervention?
a. Tell the father that a repeat dose of medication should not be
given
b. Verify the prescribed medication regimen
c. Determine if the infant has been exposed to others who are ill
d. Ask the father about the infant’s urinary
A
A nurse is providing teaching to the parents of a toddler about injury
prevention. Which of the following safety measure should the nurse include in
the teaching?
A nurse is providing teaching to the parents of a toddler about injury
prevention. Which of the following safety measure should the nurse include in
the teaching?
C
A nurse is assessing an infant with appendicitis, which of the following are
expected findings? Select all that apply
a. Vomiting
b. Jaundice
c. Bradycardia
d. Right lower quadrant pain
e. Fever
ADE
A nurse is caring for a child who received penicillin IM 15 minutes ago. The
child is now irritable and restless. Which of the following is the priority action
for the nurse to take?
a. Administer diphenydramine
b. Assess for laryngeal edema
c. Initiate continuous ECG monitoring
d. Give Epinephrine IV push
B
A nurse is providing teaching to the parents of a 9-month-old infant who is
suspected of having spastic cerebral palsy. Which of the following statements
is appropriate for the nurse to make?
a. “Use an infant walker to increase you baby’s mobility.”
b. “Your baby may loose appetite.”
c. “Physical therapy will be implemented to reduce contractures.”
d. “Your baby’s immunization schedule will be altered.”
C
A nurse is reviewing a school-aged child’s family’s health history. Which of he
following indicates a need to obtain lipid screening for the child:
a. Grand parent has type 1 Diabetes Mellitus
b. Sibling who has cystic fibrosis
c. Parent who has high cholesterol
d. Parent who has cardiac dysrhythmia
C
A nurse is providing discharge teachings for the parents of a child who has
leukemia and is receiving vincristine. Which of the following should the nurse
include in the teaching:
a. Keep the child out of the sun
b. Increase the child’s intake of fluids
c. Monitor the child’s heart rate
d. Assess the child for epistaxis
D
A nurse is caring for an infant who has tracheal esophageal fistula. Which if
the following is an appropriate action for the nurse to take?
a. Position the infant prone
b. Prepare the infant for surgery
c. Administer zantac
d. Thicken the infants formula
B
A phone triage nurse is talking to the parents of a toddler who states, “My
child has placed a bead in his nose and I don’t know what to do”. Which of the
following is an appropriate response by the nurse:
a. Try removing the bead using a pair of tweezers
b. Take your child to the pediatrician in the morning
c. Take your child to the emergency department now
d. Have your child blow his nose to dislodge the bead
C
A nurse is teaching an adolescent who has a prescription for nystatin (Troche)
orally. Which of the following should the nurse include in the teaching:
a. “Rinse immediately following the troche.”
b. “You should avoid taking the troche with milk.”
c. “Avoid taking anything by mouth 30 mins after taking the troche.”
d. “You should chew the troche completely.”
C
A nurse is caring for a child who has a tracheostomy, which of the following
techniques should the nurse to suction the child?
a. Insert the catheter 2cm beyond the end of the tracheostomy tube
b. Remove the catheter while applying intermittent suction
c. Instill saline to loosen secretions while suctioning
d. Continue suctioning until the secretions are removed
C
A toddler is admitted to the hospital with gastroenteritis and positive for a
rotavirus. For which of the following should the nurse wear a gown and don
gloves?
a. Delivering the food tray
b. Administering medication
c. Assessing the IV site
d. Changing the bed
D
A nurse is caring for a child who is postoperative, which of the following
findings indicates the need for administration of naloxone?
a. Crackles in the lung bases
b. Respiratory depression
c. Nausea and vomiting
d. Tachycardia
B
A nurse is assessing a 3-year-old client. Which of the following developmental
milestones should the nurse expect the child to demonstrate?
a. Stacking 8 blocks
b. Printing one to two letters
c. Tying shoe laces
d. Using seven word sentences
A
A nurse is caring for an adolescent following a lumbar puncture. Which of the
following is an appropriate action for the nurse to take?
a. Initiate NPO status
b. Place the client in a supine position
c. Place a moist warm pack on the lower back
d. Apply and eutectic mixture local anesthetics to the puncture site
B
A nurse is planning care for a toddler admitted with acute gastroenteritis.
Which of the following should the nurse expect to give?
a. Oral rehydration solution
b. Bananas or apple sauce
c. Chicken or beef broth
d. Hypertonic IV solutions
A
A toddler diagnosed with Tetralogy of Fallot becomes hypercapnic with
worsening cyanosis. Which of the following actions should the nurse take
first?
a. Place the toddler in knee chest position
b. Initiate Iv fluid replacement
c. Provide 100% oxygen by face mask
d. Administer morphine
A
A child admitted for acute nephrotic syndrome had been receiving prednisone
by mouth for the past week. After reviewing the child’s lab results, which of
the following should the nurse report to the primary care provider?
a. Serum sodium 142 mEq/L
b. Serum potassium 4.0 mEq/L
c. White blood cell count 3,000 mm3
d. Platelet count of 298,000/L
C
A nurse is providing education to the parents of an infant who is being treated
with Pavlik harness. Which of the following actions is appropriate when
teaching the parents about home care measures:
a. Adjust the infant’s harness once a week
b. Ensure the infant wears the shirt under the harness
c. Apply powder on harness after bathing
d. Maintain the infant in an upright position
B
A nurse is caring for an infant who is in the last stage of neuroblastoma. The
parents ask, “How can we best help our child now?” Which of the following
responses by the nurse is appropriate?
a. “Encourage you child’s friends to visit.”
b. “Stay close to your child.”
c. “Allow your child to see you cry.”
d. “Talk to your child about the meaning of death.”
b
A nurse is providing teaching to the parents to a school age child
following the placement of a ventricular peritoneal shunt. This nurse
understands teaching has been effective when the parents identify
which of the following as an indication that the shunt has been
displaced?
a. Decreased urine output
b. Decreased head circumference
c. Elevated temperature
d. increased sleeping
d
A nurse is caring for a 4 year old child. After reviewing the chart, which of the
following is an appropriate action for the nurse to take? (Click on the exhibit
below for additional information)
a. Insert a nasogastric tube for suctioning
b. Palpate the child’s abdomen for rebound tenderness
c. Prepare the child for abdominal CT scan
d. Initiate a diet high in protein and calories
c
A nurse is caring for an adolescent who is receiving fentanyl via epidural
route. Which of the following is a priority action for the nurse to take:
a. Assess skin around the catheter site
b. Check blood pressure
c. Assess pain level
d. Check oxygen saturation
d
A nurse in an acute care facility is caring for a 14-month old toddler who has
E.coli. Which of the following actions is appropriate for the nurse to take?
a. Administer opioids for pain
b. Give an oral antidiuretic agent
c. Implement a BRAT diet
d. Initiate contact precautions
d
A nurse is providing teaching to the parents of a toddler with failure to thrive.
Which of the following should the nurse include in the teaching:
a. Hold the infant face to face to maintain eye contact
b. Alternate things between several family members
c. Introduce several new foods to stimulate the infant’s interest
d. Provide a stimulating infant to keep the infant awake
a
A nurse is providing discharge teaching to the parent of a child who
experienced status asthmaticus. Which of the following responses by the
parent indicates an understanding of the teaching?
a. “I will perform chest physiotherapy during an acute attack.”
b. “When using a metered-dose inhaler, my child should inhale the
quickly exhale medication.”
c. “My child will use his bronchodilator before bedtime to prevent
wheezing.”
d. “I will call the doctor if my child becomes anxious and restless at
night.”
d
A 10-month-old infant is undergoing a well infant check up. Which of the
following assessment findings should concern the nurse?
a. The infant is unable to walk alone
b. The infant’s Moro reflex is absent
c. The infant’s anterior fontanel was opened
d. The infant needs assistance to sit up
d
A nurse is communicating with a child who has hearing loss. Which of the
following actions should the nurse take?
a. Exaggerate pronunciation of words
b. Change positions frequently to maintain attention
c. Use touch to initiate communication
d. Avoid using facial expressions when speaking
c
An early school aged child continues to have mild discomfort after
administration of an analgesic. Which of the following actions should the
nurse use?
a. Use guided imagery
b. Give the child a large coconut to find different designs
c. Encourage the child to take a deep breath
d. Teach the child to picture a stop sign whenever the pain begin
d
A nurse is providing education about dietary modifications to the parent of a school age child who
has glomerulonephritis. Which of the following information should the nurse include in the teaching?
A. Increase the child calcium intake
B. Decrease the Child’s sodium intake
C. Increase the child’s intake of carbohydrates
D. Decrease the child’s fat intake
B
A nurse is providing anticipatory guidance to a parent of a 1- month-old infant. The nurse should
include that it is recommended to start this series of which of the following immunization first?
A. Varicella
B. measles, mumps, rubella
C. Inactivated poliovirus
D. Hepatitis A tetra
C
A nurse is reviewing the laboratory report of a toddler who has hemolytic uremic syndrome. Which
of the following findings should the nurse expect?
A. Creatinine 0.3 mg/dL
B. Hbg 18 g/dL
C. Urine casts absent
D. BUN 28 mg/dL
D
A nurse on a pediatric intensive care unit is caring for a toddler who weighs 12 kg (26.5 Ib) and is
postoperative following open heart surgery. Which of the following findings should the nurse report to
the provider?
A. Skin temperature 36C (96.8 F)
B. Pedal and posterior tibial pulses of 2+
C. Urine output of 15 mL in the last 2 hr
D. Drainage from the chest tube of 22 mL in the last hour.
C
A nurse is providing dietary teaching to a parent of a 10-month-old infant who has phenylketonuria.
Which of the following responses by the parent indicate an understanding of the teaching?
A. My daughter can’t drink orange juice
B. I will steam carrots and cut them into small pieces for her.”
C. I should ensure that my daughter eats one ounce of meat every day.”
D. I will switch her to whole milk now that she is old enough.”
B
A nurse is providing teaching to the parent of a preschool-age child who has celiac disease. Which
of the following instructions should the nurse include?
A. Your child will be on a gluten-free diet for the rest of her life.”
B. Your child will need to follow a low-protein diet temporarily.”
C. You should place your child on a high-fiber diet when she has an exacerbation.”
D. You should replace white flour with wheat flour when preparing meals for your child.”
A
A nurse is administering albuterol by metered dose inhaler for a preschool-age child who is
experiencing an asthma exacerbation. Which of the following findings should the nurse report to the
provider?
A. Respiratory rate 24 /min
B. Peak flow rate of 80% expected/desired finding
C. Intercoastal retractions
D. Elevated heart rate
C
A nurse is caring for a school-age child who has heart failure. Which of the following findings
should the nurse expect? (select all that apply.)
A. Tachycardia
B. Weight loss
C. Cyanosis
D. Dyspnea
E. Bounding peripheral pulses
ACD
A nurse in an emergency department is assisting a toddler who has a head injury. Which of the
following findings should the nurse report to the provider?
A. Glasgow coma scale score of 15
B. Respiratory rate 25/min
C. Vomiting-
D. Negative Babinski reflex
C
During a well-baby visit, the parent of a 2- week-old newborn tells the nurse, “My baby always
keeps her head tilt to the right side. The nurse should further assess which of the following areas?
A.Sternocleidomastoid muscle
B. Posterior fontanel
C. Trapezius muscle
D. Cervical vertebrae
A
A nurse is caring for a single mother of a 6-month-old infant. During a well-baby visit, the mother
expresses feeling “inexperience” in caring for the baby. The nurse should recommend which of the
following community resources?
A. Respite childcare
B. Parent management training
C. Support group for postpartum depression
D. Parent enhancement center
D
A nurse is admitting an infant who has GERD. Which of the following is the priority assessment
finding?
A. Regurgitation
B. Wheezing
C. Excessive crying
D. Weight loss
B
A nurse is caring for an infant who has severe dehydration. Which of the following clinical findings
should the nurse expect?
A. Capillary refill 3 seconds
B. Rapid respirations
C. Bradycardia
D. Warm extremities
b
A nurse is caring for a child who has impetigo contagiosa that developed in the hospital. Which of
the following actions should the nurse take?
A. Report the disease to the state health department.
B. Administer amphotericin B IV.
C. Initiate contact isolation precautions.
D. Applying lidocaine ointment topically.
c
A nurse is providing discharge teaching to the parents of a school-age child who has cystic fibrosis.
Which of the following responses by the parents indicate an understanding of the teaching?
A. I will limit my child’s daily fluid intake.”
B. I will restrict the amount of sodium in my child’s diet.”
C. I will give my child pancreatic enzymes with snacks and meals.”
D .I will prepare low-fat meals with limited protein for my child.”
c
A nurse is providing teaching to the parent of a school-age child who has ADHD and a new
prescription for methylphenidate. The nurse should explain that this medication will have which of the
following therapeutic effects?
A. Promoting rest
B. Improving appetite
C. Reducing anxiety
D. Increasing focus
D
A nurse is teaching an adolescent how to manage his cystic fibrosis. which of the following
statements by the adolescent indicates an understanding of the teaching?
A. I will take fewer enzymes when I eat high-fiber foods.”
B. I will be excused from physical education classes.”
C. I will limit my calcium intake to prevent kidney stones.”
D. I will increase my intake of vitamin D
D
A nurse in a provider’s office is caring for a preschool-age child who might have acute epiglottitis.
Which of the following actions should the nurse take?
A. Examine the oral mucosa using a tongue depressor.
B. Obtain a sterile throat culture.
C. Provide humidified oxygen via nasal cannula.
D. Allow the child to sit in a comfortable position.
C
A nurse is reviewing the laboratory report of a school age child who has rheumatic fever. Which of
the following laboratory findings should the nurse expect?
A. Decreased BUN
B. Increased antistreptolysin O titer (ASO)
C. Increased immunoglobulin G (IgG)
D. Decreased erythrocyte sedimentation rate (ESR)
B
A nurses administering an opioid to an adolescent who is in sickle cell crisis. Which statement is
true regarding opioid pain management?
A. Oral opioid doses should be larger than parenteral doses
B. Oral opioids should not be combined with other types of pain relievers.
C. Opioid doses should be titrated until sedation occurs
D. Opioid doses should be used for mild pain
A
A nurse is preparing to perform peritoneal dialysis for a child who has an elevated serum creatinine
level. After explaining the procedure, which of the following action should the nurse plan to take?
A. Initiate IV access
B. Keep the dialysate refrigerated until time of infusion
C. Check the fistula site for a bruit.
D. Obtain the child’s weight
D
A nurse is caring for a preschool-age child who is postoperative following a tonsillectomy and is
clearing her throat frequently. Which of the following actions should the nurse take first?
A. Give the child small sips of water.
B. Observe the child’s throat with a flashlight.
C. Administer an Analgesic.
D. Offer the child an ice collar.
B
A nurse is planning care for a child immediately following the insertion of a chest tube for
continuous suction with a closed drainage system. Which of the following interventions should the
nurse include in the plan of care?
A. Change the chest tube insertion site dressing every 12 hr.
B. Report the presence of tidaling of fluid in the water seal chamber.
C. Ensure continuous bubbling is present in the suction control chamber
D. Record the amount of chest tube drainage every 2 hr.
C
A nurse is assisting an adolescent who has Cushing’s syndrome. Which of the following findings
should the nurse expect?
A. Cachectic appearance
B. Blood glucose 320 mg/dL
C. Potassium 4.2 mEq/L
D. Advanced bone age
B
A nurse is caring for a child who has acute glomerulonephritis. Which of the following findings
should the nurse expect?
A. Temperature 39 C (102.2 F)
B. Periorbital edema
C. Hypotension
D. Positive urine culture
BA
A nurse is providing postoperative care for a child following an arterial cardiac catheterization.
Which of the following actions should the nurse take?
A. Keep the affected extremity straight for at least 6 hr.
B. Monitor output using an indwelling urinary catheter for the first 24 hr.
C. Remove the child’s pressure dressing after the first 4 hr.
D. Maintain the child’s NPO status for 4 to 6 hr.
A
A nurse in a provider’s office is providing teaching to the parents of a preschooler who has Down
syndrome. Which of the following statements by one of the parents indicate an understanding of the
instructions?
A. We’ll have soft music playing in the background when we teach our son in new skill
B. We’ll explain that it’s best for our son to wait until kindergarten to start going to school
C. we’ll be sure to demonstrate a new skill before expecting our son to perform it .”
D. We’ll focus on our son understanding the principles of a skill rather than mastering it.”
C
A nurse is providing discharge teaching to a parent of a toddler who has a ventriculoperitoneal
shunt. which of the following statements by the parents indicates an understanding of the teaching?
A. My child will need to take prophylactic antibiotics daily until they shunt is removed.”
B. I should call my doctor if my child begins vomiting.”
C. I should pump the shunt at the same time each day.”
D. I should check my child’s heart rate before administering medications.”
B
A nurse is assessing a 3-month-old infant who has diarrhea. Which of the following findings should
the nurse expect?
A. Bulging fontanel
B. Decreased heart rate
C. Polyuria
D. Increased hematocrit
D
A nurse is providing teaching to a parent of an infant who has a 1 cm (0.4 in) umbilical hernia.
Which of the following instructions should the nurse include in the teaching?
A. Place a belly band around you baby’s umbilicus during the day.”
B. You should place your baby on her abdomen to sleep at night.”
C. Your baby will need surgery if it doesn’t close by 2 years of age.”
D. The bulge can temporarily enlarge when your baby cries.”
D
A. nurse is admitting a child who has pertussis. Which of the following transmission-based
precautions should the nurse initiate?
A. Airborne
B. Contact
C. Protective
D. Droplet
D
A nurse is providing teaching to the parent of a school-age child who has diabetes mellitus about
managing diabetes during illness. Which of the following statements by the parent indicate an
understanding of the teaching?
A. I will monitor my child’s blood glucose levels every 8 hours.
B. I will offer my child 20 grams of carbohydrate every 2 hours.
C. I will withhold my child’s dose of insulin when his appetite is poor
D. I will increase the amount of fluids I offer my child.
d
A nurse is providing discharge teaching to the parents of a toddler who has iron deficiency anemia
and new prescription for ferrous sulfate elixir. Which of the following instructions should the nurse
include?
A. Don’t allow your child to have orange juice while taking this medication.
B. Administer this medication to your child with a dropper.
C. Give your child this medication with a glass of milk.
D. Stop this medication if you child’s stools are a tarry green color.
B
A nurse is providing teaching to an adolescent who has Vulvovaginitis. Which of the following
statements should the nurse include in the teaching? This is a trick question. No consensus.
A. Wear a feminine deodorant pad for vaginal drainage.”
B. Wear nylon underwear at night.”
C. Apply scented baby powder to absorb residual moisture.”
D. Apply a warm, moist compress three times per day.
D
A nurse is providing teaching to an adolescent who has vulvovaginitis. Which of the following statements should the nurse include in the teaching?
a. wear a feminine deodorant pad for vaginal drainage
b. wear a nylon underwear at night
c. apply scented baby powder to absorb residual moisture
d. apply a warm, moist compress three times per day
D
A nurse is providing discharge instructions to the parents of a toddler who has heart failure and a new prescription for digoxin. Which of the following statements indicate an understanding of the instructions?
a. we will wait to give the medication at the next scheduled time if a dose is missed
b. we will mix the medication with 1 cup of fruit juice for administration
c. we will avoid giving our child water for 1 hour after administering the medication
d. we will repeat the dose if our child vomits shortly after administration
a
A nurse is planning on in-service for parents of school-age children about the treatment of pediculosis capitis. Which of the following instructions should the nurse plan to include in the teaching?
a. soak the child’s hair brushes in vinegar between uses
b. applied medication to the child’s scalp twice daily until the symptoms subside
c. remove nits from the child’s hair using a fine-tooth comb
d. discard the child’s nonwashable items
a
A nurse is assessing an adolescent who has infectious mononucleosis. Which of the following
findings should the nurse expect?
A. Cervical adenopathy
b. strawberry tongue
c. koplik spots
d. uncontrolled drooling
A
A nurse is preparing to assess a 4-year-old child’s visual acuity. Which of the following actions
should the nurse plan to take?
A. Position the child 4.6 meters (15 feet) from the chart
B. Use a trumbling E chart for the assessment
C. Test the child without glasses before testing with glasses.
D. Assess both eyes together first, then each eye separately.
B
A nurse in an emergency department is caring for a child following an overdose of acetylsalicylic
acid. Which of the following medications should the nurse plan to administer?
A. Phytonadione
B. Midazolam
C. Naloxone
D. Flumazenil
A
A nurse is providing teaching to the parents of a toddler who is exhibiting negativism during
mealtimes. Which of the following statements by the nurse is appropriate?
A. Tell her she is having her favorite sandwich for lunch.”
B. Ask her if she would like to have her favorite sandwich for lunch.”
C. Ask her if she is ready to eat her sandwich for lunch.”
D. Tell her that she may have a sandwich or soup for lunch.”
D
A nurse in an emergency department is caring for a child who weighs 18 kg (39.7 Ib) and ingested
six 500 mg acetaminophen tablets 4 hr ago. Which of the following actions should the nurse take?
A. Prepare to give oral N-acetylcysteine.
B. send a child home on increased fluid intake.
C. Begin hemodialysis within the next 24 hr.
D. Perform gastric lavage with activated charcoal
A
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the inser<on of an IV catheter. Which of
the following ac<ons should the nurse plan to take?
a. Wash the site with alcohol prior to applying the cream
b. Gently rub the cream into the skin
c. Apply the cream 1 hr. before the procedure
d. Avoid removing the cream prior to the procedure.
C
A nurse is assessing a toddler who is 8 hr. postoperative following a cardiac catheterization procedure. Which of the
following findings should the nurse report to the provider?
a. Weak pedal pulse distal to the site
b. Blood pressure 102/58mm Hg
c. Bilateral cool extremites
d. Serum glucose 90mg/dL
C
A charge nurse is teaching a group of nurses about identifying child abuse. Which of the following findings should the
nurse identify as a potential indicator of child abuse?
a. A toddler repeatedly refuses to lie a nurse auscultate his lungs
b. An 8-month-old infant cries when his parents leave the room
c. A mother is hesitating to comfort her 6-month-old infant
d. A toddler has bruises on his knees
C
A nurse is assessing a week old infant. The nurse should identify which of the following manifestations can indicate neonatal abstinence syndrome?
a. Frequent coughing
b. Constipation
c. Excessive sucking
d. Lethargy
C
A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month-old infant. Which of the following actions should the nurse plan to take?
a. Use a 12 gauge catheter to the start the IV
b. Start the IV in the infant’s foot
c. Cover the insertion site with an opaque dressing
d. Change the IV site every 3 days
C
A nurse is performing a health assessment for a 6 month old infant. The nurse should begin the assessment by performing which of the following actions while the infant is quiet and sitting on the guardians lap?
a. Obtaining the infant’s health history from the guardian
b. Checking the infant reflexes
c. Listening to the infinite heart and lung sounds
d. Looking in the infants eyes
C
a nurse is teaching the guardian of an infant who has congestive heart failure about methods to preserve energy during bottle feeding. Which of the following statements by the guardian indicates a clear understanding of the teaching?
a. I will feed my baby every 2 hours
b. I will allow my baby to suck for 45 minutes during each feeding
c. I will use a low calorie formula for my baby’s feeding
d. I will stroke my baby’s cheek during feeding
a
A nurse is providing a teaching to the guardian of a 2year old about typical toddler behavior. Which of the following behaviors should the nurse include?
a. Frequency negative responses
b. Less emotionally labile
c. Increased dependency
d. Resistant to routines
A
A nurse is caring for a 1 year old infant who has GERD. Which of the following actions should the nurse take to promote sleep for the infant?
a. Place the infant in supine position to sleep
b. Place the infant in a left lateral position’
c. Offer feedings just before bedtime
d. Provide the infant with a bottle of milk at bedtime
A
A nurse is caring for an adolescent who has scoliosis and is refusing to wear a back brace which of the following statements should the nurse make?
a. I think you are worrying too much about wearing the brace.
b. Let’s sit down and discuss why you do not want to wear the brace.
c. your primary care provider said you have to wear a brace.
d. At first it is hard to wear a back brace but it gets easier over time.
B
A nurse is caring for a 4-year old child who is postoperative following an appendectomy. Which of the following pain rating scales should the nurse use to assess the child’s need for pain medication ?
a. word -graphic
b. Visual analog
c. FACE
d. Numeric
C
nurse is caring for an infant who has increased intracranial pressure (ICP). Which of the following should the nurse identify as late finding of (ICP) ?
a. Flexion posturing
b. increase sensory response to painful stimuli.
C increase heart rate
d. Tachypnea.
A
PEDS PROCTOR EXAM1. A nurse is preparing to assess a 4-year-old child’s visual acuity. Which of the following actions should the nurse plan first?A. Use a tumbling E chart for the assessmentB. Position the child 4.6 meters (15 feet) from the chartC. Asses both eyes together first, then each eye separatelyD. Test the child without glasses before testing with glasses2. A nurse is providing discharge teaching to a parent of a child who has juvenile idiopathic arthritis and a new prescription of prednisone/etanercept. Which of the following statements should the nurse include in the teaching?A. Monitor your child for indications of infectionB. Discontinue this medication if gastrointestinal upset occursC. Expect that this medication will stimulate growth spurtD. Limit your child’s intake of potassium-rich foods3. A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?A. An adolescent who has hepatitis AB. A toddler who has seasonal influenzaC. A preschool-age child who has pediculosis capitisD. A school-age child who has viral conjunctivitis4. A nurse is providing teaching to an adolescent who has vulvovaginitis. Which of the following statements should the nurse include in the teaching?A. Apply a warm, moist compress three times a dayB. Apply a scent baby powder to absorb residual moistureC. Wear a feminine deodorant pad for vaginal drainageD. Wear a nylon underwear at night5. A nurse is creating a plan of care for a school-age child who has nephrotic syndrome. Which of the following interventions should the nurse include? (SATA)A. Provide a low sodium dietB. Encourage increased fluid intakeC. Assess for protein in the urineD. Initiate contact precautionsE. Obtain a daily weight
- A nurse in a pediatric unit is caring for a school-age child following a cardiac catheterization. Which of the following interventions would the nurse take?A. Maintain NPO status for 24 hours following the procedureB. Administer meperidine for pain every 4 hoursC. Perform a sterile dressing change 8 hours after the procedureD. Keep the affected extremity straight for 6 hours.7. A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates understanding of the teaching?A. I should mix the medication with 4 ounces of child’s favorite juiceB. I should give me child water after giving the medicationC. I should give my child another dose if he vomits right after taking the medicationD. I should give the medication with foods that are high in fiber8. A nurse is caring for a 9-year-old child who has major burns to her face and upper torso. Which of the following actions should the nurse take first?A. Administer a tetanus vaccineB. Give pain medicationC. Begin enteral feedingsD. Initiate a crystalloid IV bolus9. A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following should the nurse include in the plan of care?A. Schedule routine oral care every 8 hoursB. Administer oral viscous lidocaineC. Moisten the mucous with lemon glycerin swabsD. Cleanse the gums with saline soaked gauze10. A nurse in a community health clinic is assessing the needs of a single parent who has three young children and works full time. Which of the following resources should the nurse recommend?A. 12-step support groupB. Respite child-careC. Child home health careD. Counseling for depression11. A nurse is caring for a child who has prescription for fluticasone and has developed white patches and sores in his mouth. Which of the following is an appropriate action forthe nurse to take?2
A. Encourage the use of a spacerB. Withhold the medication until the lesions healC. Obtain a prescription for oral prednisoneD. Collect a culture from the lesions12. A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?A. Seal soft toys in a plastic bag for 14 daysB. Apply bacterial ointment for lesionsC. Administer acyclovir PO two times per dayD. Soak hairbrushes in boiling water for 10 minutes13. A nurse in an emergency department is caring for a child who is epiglottis. Which of the following actions should the nurse take?A. Provide nebulizer aerosol therapyB. Administer IV antibioticsC. Inspect the tonsils using a tongue depressorD. Collect a throat culture14. A nurse is planning care for a child who is placed in skin traction. Which of the following is the priority action for the nurse to take?A. Increase fluid intakeB. Maintain a proper body alignmentC. Use an alternate pressure mattressD. Monitor pedal pulses15. A nurse is preparing to administer ondansetron 0.15 mg/kg IV to a child who is receiving chemotherapy and weighs 29.4 kg. available is ondansetron 4mg/2mL solution. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero).Answer: 2.2 mL16. A nurse is performing a physical assessment of a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse expect?A. HypotensionB. Increased urinary outputC. Flushed skinD. Facial edema3 - A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of the following findings should the nurse expect?A. HypothermiaB. Pinpoint pupilsC. Hyperactive reflexesD. Ataxia18. A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling. Which of the following actions should the nurse take first?A. Prepare the toddle for nasotracheal intubationB. Insert an IV catheter for the toddlerC. Obtain a blood culture from the toddlerD. Administer an antibiotic to the toddler19. A nurse is caring for an infant who has a patent ductus arteriosus. The nurse should identify that the defect is at which of the following locations of the heart? (you will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your assessment)Answer:20. A nurse is caring for an infant who has hydrocephalus and ventriculoperitoneal shunt malfunction. Which of the following assessment findings indicates that the infant is experiencing increased intracranial pressure?A. Increased appetiteB. IrritabilityC. Flat fontanelD. Tachycardia21. A nurse is assessing an infant who has iron deficiency anemia. Which of the following findings should the nurse expect?A. Increased hemoglobin levelB. Hyperactive muscle toneC. BradycardiaD. Pale conjunctiva22. A nurse is caring for a child who received partial thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractions. Which of the following actions should the nurse take? (SATA)A. Provide a high-calorie dietB. Administer analgesics IM4
C. Remove splints during sleepD. Change dressing using aseptic techniqueE. Monitor intake and output23. A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?A. Bruising around the wristsB. Abrasions on the kneesC. Weight in 45th percentileD. Front deciduous teeth missing24. A nurse is assessing an 18-month-old child during a well-child visit. Which of the following findings should the nurse report to the provider?A. The child crawls to navigate the roomB. The child has frequent temper tantrumsC. The child consistently throws items to the floorD. The child scribbles on the wall with a crayon25. A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is inadequately dehydrated?A. Weight loss 7%B. Capillary refill 1 secondC. BradycardiaD. Respiratory rate 26/min26. A nurse is providing teaching about injury prevention to the parents of a toddler. Which of the following safety measures should the nurse include in the teaching?A. Adjust the water heart temperature to 54 C (129.2 F)B. Check clothing for loose buttonsC. Provide balloons for playD. Place screens on all windows27. A nurse is caring for a school-age child who is in 90/90 skeletal traction. Which of the following actions should the nurse take?A. Release the traction to allow the child to batheB. Place the child on an alternating pressure mattressC. Adjust the weights to allow the child to turnD. Ensure that the pulley mechanism is attached to the skin5 - A nurse is caring for a child who has increased intracranial pressure and is unconscious due to a closed head injury. Which of the following actions should the nurse take?A. Maintain the child’s neck in a flexed positionB. Turn the child side to side every 2 hoursC. Initiate seizure precautionsD. Perform chest percussion as needed29. A nurse is providing teaching to the parents of a school-age child newly diagnosed with seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?A. Clear the area of hard objectsB. Minimize movement of the limbsC. Insert a tongue blade between the teethD. Place the child in a prone position30. A nurse is providing teaching to a parent of an infant who has diaper rash. Which of the following statements by the parent indicates an understanding of the teaching?A. I will use antibacterial soap to wash the rash with each diaper changeB. I will keep the area warm and moistC. I will use super-absorbent disposable diapersD. I will sprinkle talcum powder over the affected area twice daily31. A nurse in a provider’s office is assessing the vital signs of a 1-year-old toddler. Which of the following findings should the nurse report to the provider?A. Blood pressure 88/42 mm HgB. Heart rate 110/minC. Respiratory rate 54/minD. Temperature 37.7 C (99.9 F)32. A nurse is teaching about growth and development to a parent of a 12-year-old child. The nurse should instruct the parent to expect a child to exhibit which of the following characteristics during early adolescence?A. Emotional separation from parentsB. Mood swingsC. Increased self-esteemD. Decelerating growth rate33. A nurse is caring for a child who is 2 hours postoperative. Which of the following actions should the nurse take first? (Click the “exhibit” button for additional information about the client. There are three tabs that contain separate categories of data).A. Recheck the child’s temperature6
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B. Determine the child’s sedation levelC. Assess the child’s pain levelD. Compare the child’s pedal pulses34. A nurse is assessing an adolescent who has Cushing’s syndrome. Which of the following findings should the nurse expect?A. Potassium 4.2 mEq/LB. Blood glucose 320 mg/dLC. Advanced bone ageD. Cachectic appearance35. A nurse is caring for a preschool-age child who is 2 hours postoperative following a tonsillectomy and adenoidectomy. Which of the following manifestations should the nurse report to the provider?A. TachycardiaB. Blood-tinged mucusC. Dark brown emesisD. Halitosis36. A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the findings to the provider?A. CoughingB. TachypneaC. PharyngitisD. Rhinorrhea37. A nurse is admitting an infant who has GERD. Which of the following is the priority assessment finding?A. Weight lossB. Excessive cryingC. WheezingD. Regurgitation38. A nurse is planning care for a child who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?A. Administer meperidine as needed for painB. Initiate bed restC. Limit fluid intakeD. Apply cord compresses to affected joints7
- A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new prescription for dornase alfa. Which of the following instructions should the nurse include in the teaching?A. Store the medication in the refrigeratorB. Use a spacer with this medicationC. Administer every 4 hours as needed for coughD. Mix the medication with albuterol solution prior to administration40. A nurse is caring for a preschool-age-child who has a terminal illness. Which of the following findings should the nurse expect?A. Believes the condition is a punishmentB. Expresses interests in the funeral arrangementsC. Accepts death is inevitableD. Feels excessive anxiety about physical changes41. A nurse is reviewing the laboratory values of a school-age child who has nephrotic syndrome. Which of the following laboratory results should the nurse expect?A. Serum sodium 144 mg/dLB. Serum protein 4.2 g/dLC. Hgb 12 g/dLD. BUN 15 mg/dL42. A nurse is planning care for a school-age child who has autism spectrum disorder. Which of the following actions should the nurse include in the plan?A. Give the child three options when making choicesB. Stay with the child for long periods of timeC. Explain procedures in detail to the childD. Introduce the child to new situations slowly43. A nurse is preparing to administer morphine 0.2 mg/kg IV to a child who is postoperativeand in pain. The child weighs 34 kg. Available is morphine 1 mg/mL solution. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)Answer: 6.8 mL44. A nurse is providing teaching to a parent of an 11-month-old infant who has acute diarrhea and dehydration. Which of the following fluids should the nurse instruct the parent to provide to the infant?A. Chicken brothB. Oral electrolyte solutionC. Glucose water8
D. Half-strength apple juice45. A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?A. The risk of transmission decreases since my child is on zidovudine for 2 weeksB. My child will need to repeat his childhood immunizations since he is in remissionC. My child will need to double his medications for the next 6 monthsD. I will ensure that my child is tested for tuberculosis every year46. A nurse is caring for a school-age child who has diabetes mellitus. Which of the followingfindings should the nurse recognize as being consistent with hyperglycemia?A. PallorB. ThirstC. SweatingD. Tremors47. A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?A. A preschool-age child who has muffled voice and spontaneous coughB. An adolescent who has Crohn’s disease and a recent weight loss of 5 kg (11 lbs)C. A toddler who has nephrotic syndrome and facial edemaD. A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL48. A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?A. An adolescent who has sickle cell anemia and slurred speechB. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillinC. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change49. A nurse is preparing to administer immunization to a 3-month-old infant. Which of the following is an appropriate method to take to deliver atraumatic care?A. Use a 20-gauge needle for the injectionB. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injectionsC. Inject the immunization into the deltoid muscleD. Provide a pacifier coated with an oral sucrose solution prior to the injections9 - A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should expect that which of the following laboratory tests can contribute to confirming this diagnosis? (SATA)A. Antistreptolysin O (ASO) titerB. Blood urea nitrogen (BUN)C. Partial thromboplastin (PTT)D. Erythrocyte sedimentation rates (ESR)E. C-reactive protein (CRP)51. A nurse is reviewing the laboratory report of a school-age child who has bacterial pneumonia. Which of the following laboratory values should the nurse expect?A. WBC 18,000/mm3B. Ph 7.40C. Hgb 14 g/dLD. Creatinine 0.5 mg/dL52. A nurse is providing teaching about medication administration to the parents of a toddler who has a new prescription for liquid ferrous sulfate. Which of the following instructions should the nurse include in the teaching?A. Report tarry, green stools to the providerB. Administer the drops with milkC. Dilute the drops with water prior to administrationD. Provide an antacid prior to administration53. A nurse in an emergency department is caring for a child following an overdose of acetylsalicylic acid. Which of the following medications should the nurse plan to administer?A. FlumazenilB. PhytonadioneC. MidazolamD. Naloxone54. A nurse is planning care for a newly admitted child who has rotavirus. Which of the following precautions should be implemented?A. AirborneB. ContactC. ProtectiveD. Droplet55. A nurse is developing a plan of care for child who is dying. Which of the following measures should the nurse implement to the child and his family?10
A. Maintain consistent nursing staff assignmentsB. Ask the parents to leave the room for the proceduresC. Select one family member to receive informationD. Limit the number of visitors in the client’s room56. A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?A. Have the child flex his head when securing the tiesB. Place the child in Trendelenburg position when performing careC. Clean around the stoma with full-strength hydrogen peroxideD. Use clean technique to change the tracheostomy tube57. A nurse in the emergency department is caring for a child who has a temperature of 39.1 C (102.4 F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?A. Prepare the child for a lumbar punctureB. Administer an antipyretic to the childC. Dim the lights in the child’s roomD. Implement droplet precautions for the child58. A nurse is caring for a toddler who has a shirt leg cast. Which of the following findings should the nurse report to the provider?A. Positive pedal pulse in the distal extremityB. Pallor of the distal extremityC. Mobility of the distal extremityD. Warm temperature of the distal extremity59. A nurse is caring for a newly admitted toddler who has acute diarrhea. Which of the following actions should the nurse take first?A. Initiate contact precautionsB. Administer an antibioticC. Obtain a stool specimen for cultureD. Give 0.9% sodium chloride IV bolus60. A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?A. You may tolerate plain milk better than chocolate milkB. You can drink milk on an empty stomachC. You can replace milk with nondairy sources of calciumD. You should consume flavored yogurt instead of plain yogurt11 - A nurse is providing discharge teaching to the parents of a school-age child following placement of a ventriculoperitoneal shunt. The nurse should determine that the teaching was effective when the parents identify which of the following as an indication the shunt has been displaced?A. Hyperactive bowel soundsB. Elevated temperatureC. Increased sleepingD. Decreased urine output62. A nurse is providing teaching to a parent of a 2-month-old infant about immunization schedules. Which of the following statements by the parent indicates an understanding of the teaching?A. My child needs to get the MMR immunization when she’s 12 months oldB. My child needs to get the varicella immunization when she’s 6 months oldC. My child will receive the influenza immunization todayD. My child will receive the hepatitis A immunization today63. A nurse is performing a cranial nerve assessment on a school-age child. Which of the following findings indicates proper functioning of the child’s trigeminal nerve?A. The child maintains balance when standing with eyes closedB. The child has symmetrical jaw strength when biting downC. The child exhibits a gag reflex when stimulated with tongue bladeD. The child correctly identifies specific exams64. A nurse is planning care for a child immediately following the insertion of a chest tube for continuous suction with a closed drainage system. Which of the following interventions should the nurse include in the plan of care?A. Ensure continuous bubbling is present in the suction control chamberB. Report the presence of tiddling of fluid in the water seal chamberC. Change the chest tube insertion site dressing every 12 hrsD. Record the amount of chest tube drainage every 2 hrs65. A nurse is educating an adolescent following the application of an arm cast. Which of thefollowing statements by the client indicates an understanding of the teaching?A. I will sprinkle baby powder into the cast if my arm itchesB. I should limit the use of the fingers of my broken armC. I will elevate my forearm on pillows at nightD. I should expect my fingers to be swollen for several days66. A nurse in a community center is providing an in-service for parents about nutritional guidelines. Which of the following guidelines should the nurse include in the teaching?12
A. Encourage a 15-year-old to increase calcium intakeB. Provide 35 oz of milk per day to a toddlerC. Offer 8 to 10 oz of juice per day to a preschoolerD. Introduce popcorn as a health snack at 12 months of age67. A nurse is caring for a school-aged child who is experiencing pain. Which of the followingassessment teachings would be the most accurate information regarding the child’s pain?A. Ask the child to use a FACES rating scaleB. Monitor the child’s involuntary movementsC. Observe the child’s facial expressionsD. Assess the child’s pulse and respirations68. A nurse in an emergency department is assessing a school-age child who has asthma. Which of the following should the nurse identify as the priority?A. Decreased breath soundsB. Hyperresonance on percussionC. Nonproductive coughD. Pulse rate 118/min69. A nurse is caring for a child who is postoperative following surgical correction of tetralogy of Fallot. Which of the following is a manifestation of heart failure?A. Exercise intoleranceB. BradycardiaC. Weight lossD. Decreased respirations70. A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamycin. Which of the following laboratory results should the nurse report to the provider?A. Creatinine 1.4 mg/dLB. BUN 12 mg/dLC. BUN 6 mg/dLD. Creatinine 0.2 mg/dL71. A nurse is providing teaching to guardians off a school-aged child who has a seizure disorder. Which of the following factors should the nurse include as a common trigger that increases the risk of seizures?A. Prolonged headacheB. Lack of sleepC. Decreased temperatureD. Exposure to secondhand smoke13 - A nurse planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?A. Place the infant in a prone positionB. Repeat a digoxin dosage if the infant vomits within 1 hour administrationC. Provide less frequent, higher volume feedingsD. Administer cool, humidified oxygen via nasal canula73. A nurse is caring for an adolescent who is 1 hour postoperative following an appendectomy which of the following findings should the nurse report to the provider?A. Temperature of 36.4 C (97.5F)B. Muscle rigidityC. Abdominal painD. Heart rate of 63 min74. A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. Which of the following responses by the parent indicates an understanding of the teaching?A. My child should remain under a beach umbrella during morning hoursB. My child should wear a wide-brimmed hatC. I should apply a 10 spf sunscreen to my child’s entire bodyD. I should dress my child in loose-weave clothing75. A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the child’s potassium level is 3.2 mEq/L. which of the following assessment findings should the nurse expect?A. OliguriaB. Hyperactive bowel soundsC. HypertensionD. Hyporeflexia76. A nurse is assessing a school age child’s cranial nerve function. Which of the following actions should the nurse assess the child to take when assisting the accessory nerve?A. Show their teeth while smilingB. Shrug their shoulders against mild pressureC. Move their tongue in all directionsD. Follow a light in the six cranial positions77. A nurse is teaching a group of female adolescents about health eating. Which of the following instructions should the nurse include in the teaching?14
A. Consume 1500 to 1700 cal per dayB. Limit your sodium intake to 3000 milligrams per dayC. Decrease your vitamin D intake once you start to menstruateD. Increase the amount of your dietary iron intake78. A nurse in a provider’s office is preparing to administer immunizations to a 12-year-old client during a well child visit. Which of the following immunizations should the nurse plan to administer?A. Human papillomavirus (HPV)B. Hepatitis aC. Diphtheria, tetanus, and pertussis (DTaP)D. Varicella79. A nurse is assessing a school age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?A. A decrease in peripheral edemaB. An increase in venous pressureC. A decrease in cardiac outputD. An increase in potassium levels80. A nurse is teaching home care to the parents of a preschool-age child who has heart failure. Which of the following information should the nurse include in the teaching?A. Increase the child’s oxygen flow rare until the child no longer has cyanosisB. Withhold the digoxin if the child’s pulse is greater than 100/minC. Provide periods of restD. Weight the child once a month81. A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?A. Initiate airborne precautionsB. Administer aspirin for feverC. Provide the child with a warm blanketD. Assess the oral cavity for kolpik spots82. A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling. Which of the following actions should the nurse take first?A. Prepare the toddler for nasal tracheal intubationB. Administer an antibiotic to the toddlerC. Insert an IV catheter for the toddler15
D. Obtain a blood culture from the toddler83. A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestation should the nurse include as an indication for digoxin toxicity?A. PolyuriaB. DiaphoresisC. JaundiceD. Bradycardia84. A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following action should the nurse take first?A. Apply lidocaine gel to the perineum before attaching the bagB. Position the opening of the bag over the urethra and the anusC. Place a snug-fitting diaper over the drainage bagD. Stretch the perineum taut when applying the bag85. A nurse is caring for a school age child following the application of a cast to a fractured right tibia. Which of the following actions should the nurse take first?A. Administer pain medicationB. Elevate the child’s legC. Pedal the edges of the castD. Teach the child about cast care86. A nurse is preparing to administer prescribed medication to a toddler whose parent is nearby. Which of the following actions should the nurse take to identify the toddler?A. Ask another nurse to confirm the toddler’s indentB. Check the toddler’s ID band against medical recordC. Ask the parent to confirm the toddler’s identityD. Check the toddler’s room number against their ID bracelet87. A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?A. Increased urine outputB. Increased respiratory rateC. Capillary refill of 2 secondsD. Hypertension16 - A nurse is caring for a three-month-old infant who has a cleft of soft palate. Which of thefollowing actions should the nurse take?A. Postpone burping the infant until after completing each feedingB. Feed the infant 177.4 mL (6 oz) of formula three times each dayC. Discontinue feeding if the client’s eyes become wateryD. Elevate the infants head to a 10-degree angle during feedings89. A nurse is providing teaching about home care to the parents of a child who has scabies. Which of the following instructions should the nurse include in the teaching?A. Apply petroleum jelly to the affected areasB. Soak combs and brushes in boiling water for 10 minsC. Treat everyone who came into close contact with the childD. Wash the child’s hair with shampoo containing ketoconazole90. A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care?A. Initiate contact precautions for the childB. Maintain a patent intravenous catheterC. Encourage frequent physical activity to increase bone massD. Provide a high calorie, low protein diet91. A nurse is assisting an infant who has acute otitis media. Which of the following findings should the nurse expect? (SATA)A. FeverB. Increased appetiteC. CryingD. Enlarged sub clavicular lymph nodeE. Restlessness92. A nurse is admitting a child who has acute epiglottis. Which of the following actions should the nurse take?A. Obtain a throat cultureB. Assist the child into supine positionC. Check oxygen saturation every 4 hoursD. Initiate droplet isolation precautions93. A nurse in a provider’s office is assisting the vital signs of a two-year-old child at a well child visit. Which of the following findings should the nurse report to the provider?A. Blood pressure 118/74 mm Hg17
B. Respiratory rate 26/minC. Temperature 37.2 (99 F)D. Pulse rate 98/min94. A nurse is providing teaching to a 10-year-old child who is scheduled for an arterial cardiac catheterization. Which of the following information should the nurse include in the teaching?A. You will have your dressing removed 12 hours after the procedureB. You will need to keep your leg straight for 8 hours following the procedureC. You will be on bed rest for 2 days after the procedureD. You will be on clear liquid diet for 24 hours following the procedure95. A nurse in an emergency department is caring for a preschool age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?A. HyperpyrexiaB. PolyuriaC. Neck vein distentionD. Jaundice96. A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication of receiving this vaccine?A. Temperature of 37.2 (99 F)B. Upper respiratory infection 2 days agoC. Allergy to neomycinD. Family history of seizures97. A nurse is planning care for a 6-month-old infant who has bacterial meningitis. Which of the following interventions should the nurse include in the plan of care?A. Keep the television on in the room to provide background noiseB. Provide frequent range of motion to the neck and shouldersC. Pad the side rails of the cribD. Place the infant in a semiprivate room98. A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include in the teaching?A. The test will measure the amount of chloride in your baby’s sweatB. We will measure the amount of protein in your baby’s urine over a 24-hour period.C. A nurse will insert an IV prior to the testD. Your baby will need to fast for 8 hours prior to the test18 - A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury. Which of the following actions shouldthe nurse take first?A. Check pupil reactionsB. Inspect for fluid leaking from the earsC. Examined scalp for lacerationsD. Assess respiratory status100. A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?A. Exhibit a head lag when pulling to a sitting positionB. Absent gag reflexC. Unable to roll from back to abdomenD. Unable to hold a bottle101. A nurse in a PACU is caring for a school-age child immediately following a tonsillectomy. Which of the following actions should the nurse take?A. Offer the child ice cream when alertB. Place the child in a side-lying positionC. Encourage the child to deep breaths and coughD. Instruct the child to drink fluids through a straw102. A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden death syndrome (SIDS). Which of the following statements by the parent indicates and understanding of the teaching?A. I will have my baby sleep next to me in bed during the nightB. I will move my babies stuffed animals to the corner of her crib while she sleepsC. I will dress my baby in lightweight clothing to sleepD. I will lay me baby on her side to sleep for naps103. A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?A. Use half-strength formula when feeding the infantB. Assign consistent nursing staff to care for the infantC. Keep the infant in a visually stimulating environmentD. Give the infant fruit juice between feedings104. A nurse is to administer amoxicillin 80 mg/kg/day divided into two doses to a 2-year-old client who weighs 10 kg (22lb). available amoxicillin suspension is 400 mg/5 mL.19
how many mL of amoxicillin should the nurse administer per dose? (Round the answer to the nearest whole number. Using a leading zero if it applies. Do not use a trailing zero)Answer: 10 ML105. A nurse is doing an evaluation of a 4-year-old child who has cystic fibrosis and has been receiving chest physiotherapy treatments. The nurse should identify which of the following findings as an indication that the therapy has been effective?A. Increased urine outputB. Increased expectorationC. Increased heart rateD. Reduced pain106. A nurse is caring for a preschooler who refuses to take a stat dose of oral diphenhydramine. Which of the following statements should the nurse make?A. The medication will treat your hypersensitivity reactionB. Sometimes when a child has to take medication, they feel sadC. Let me know when you want to take the medicationD. The medication isn’t bad it tastes like candy107. A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?A. Increased blood pressureB. BradycardiaC. Limb withdrawalD. Relaxed facial expression108. A nurse is providing support to a family whose infant died from sudden infant death syndrome (SIDS). Which of the following actions should the nurse take?A. Avoid discussing details of the attempt to revive the infantB. Provide a follow up phone call 1 week following the infant’s deathC. Acknowledge the family members feelings of guiltD. Discourage the parents from allowing siblings to view the body109. A nurse is teaching a group of parents about childhood immunizations. The nurseshould identify that the infant should receive the first dose of which of the following immunizations at 12 months of age?A. Human papillomavirusB. Hepatitis BC. VaricellaD. Inactivated Polio virus20 - A nurse is caring for a school-age child who is 1 hour postoperative following a tonsillectomy. Which of the following actions should the nurse take? (SATA)A. Administered an analgesic to the child on a scheduled basisB. Maintain the child in a supine positionC. Provide cranberry juice to the childD. Observe the child for frequent swallowingE. Discourage the child from coughing111. A nurse is communicating with a child who has hearing loss. Which of the following actions should the nurse take?A. Exaggerate the pronunciation of wordsB. Use light tough when initiating conversationC. Maintain a neutral facial expression when speaking to the ch8ildD. Change positions frequently to maintain the child’s attention112. A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning. Which of the following information should the nurse include in the teaching?A. Increase the toddler’s protein consumptionB. Avoid foods containing milk productsC. Limit foods high in ironD. Use aspartame as a sugar substitute113. A nurse is assessing a toddler who has a history of lead poisoning. Which of the following actions should the nurse take?A. Obtain a stool specimen for lead levelsB. Inspect the skin for discolorationC. Perform developmental testing for delaysD. Initiate a low-iron diet for lead absorption114. A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the following actions should the nurse take?A. Decrease the child’s fluid intakeB. Administer furosemide IV twice per dayC. Apply warm compresses to the affected areasD. Initiate contact precautions115. A nurse is assessing a child who has multiple closed fractures of the lower extremities due to a motor-vehicle accident. The nurse should monitor the child for which of the following complications during the first 24 hours after the injury occurred?21
A. Compartment syndromeB. Renal calculiC. OsteomyelitisD. Volkmann ischemic contracture116. A nurse is teaching the guardian of a 5-year-old child who has encopresis about management of the condition. Which of the following statements by the guardian indicates an understanding of the teaching?A. I will have my child try to defecate 15 minutes after each mealB. I will increase my child’s dairy intakeC. I will have my child sit on the toilet for 20 minutes at a timeD. I will limit my child’s fluid intake117. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan?A. Pneumococcal conjugate (PCV13)B. RotavirusC. Respiratory syncytial virus (RSV)D. Measles, mumps, and rubella (MMR)118. A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?A. Administer epinephrineB. Administer oxygenC. Administer methylprednisoloneD. Administer a nebulized bronchodilator119. A nurse in an emergency department is caring for a child who has experienced a submersion injury. Which of the following is the priority action for the nurse to take?A. Obtain an ABG sampleB. Administer an IV bolusC. Apply warning blanketsD. Assist with intubation120. A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse’s priority?A. HbA1c 11.5%B. GlycosuriaC. Pre-prandial blood glucose 124 mg/dLD. Cholesterol 189 mg/dL22 - A nurse is planning to administer immunizations to a 2-month-old infant. Which of the following actions should the burse take to decrease the infant’s pain?A. Administer the injections while the infant is breastfeedingB. Ask the parents to leave the room during the injectionsC. Administer the injections in the deltoid muscleD. Apply a warm pack to the injection site prior to administration122. A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?A. Asses the pin sites for injection once every other dayB. Encourage flexion and extension of the neckC. Reposition the client using a turning sheetD. Tighten the screws on the halo device one quarter turn every 48 hours123. A nurse is teaching the parent of a school-age child about bicycle safety. Which ofthe following instructions should the nurse include in the teaching?A. Your child should keep the bicycle at least 3 feet from the curb while riding in the streetB. Your child should walk the bicycle through intersectionsC. Your child should ride the bicycle against the flow of trafficD. Your child’s feet should be 3 to 6 inches off the ground when seated on the bicycle124. A nurse is assessing an adolescent client who has Hodgkin’s lymphoma. Which of the following findings should the nurse expect?A. Night sweatsB. Unexplained weight gainC. Decreased body temperatureD. Flushed skin 125. A nurse is preparing to perform a venipuncture to collect a blood sample from aninfant. Which of the following restraints should the nurse plan to use for this procedure?A. ElbowB. JacketC. MummyD. Mitten126. A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?23
A. TachypneaB. BradycardiaC. Increased appetiteD. Tremors127. A nurse is providing teaching to the parents of a child who has varicella about management of the disease. Which of the following instructions should the nurse include in the teaching?A. Apply calamine lotion to vesicles on the child’s skinB. Dress the child in warm clothing to promote healing of vesiclesC. Avoid giving the child a bath while vesicles are presentD. Keep the child away from others until the skin is clear of scabs128. A charge nurse is teaching a group of nurses about identifying child abuse. Whichof the following findings should the nurse identify as a potential indicator of child abuse?A. A toddler has bruises on his kneesB. A mother is hesitant to comfort her 6-month-old infantC. An 8-month-old infant cries when his parents leave the roomD. A toddler repeatedly refuses to let a nurse auscultate his lungs129. A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?A. Axillary temperature 38 C (100 F)B. Child reports pain level of 5 on the FACES scaleC. Dark brown blood noted in emesisD. Frequent swallowing130. A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first?A. Encourage the client to attend a group therapy sessionB. Assist the client if he is considering harming himselfC. Administer an antidepressant to the clientD. Assist the client in completing his ADLs131. A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following statements should the nurse include in the teaching?A. You should perform the examination once every other monthB. If you feel a hard lump, wait 1 month and retest yourselfC. Perform the examination following a warm showerD. You should notify your provider if your testes are firm, and egg shaped24 - A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?A. Place the child in a semiprivate roomB. Keep the staff visits with the child briefC. Keep the television on in the child’s room for background noiseD. Vary daily routines when providing care for the child133. A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?A. Place the child in a protected environment for 48 hoursB. Restrict oral fluids to 500 ml per dayC. Administer the pertussis vaccineD. Report the diagnosis to the public health department134. A nurse is planning to admit a preschooler from the PACU following removal of a Wilm’s tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?A. A child who has viral pneumoniaB. A child who has impetigoC. A child who has a fractured left femurD. A child who has cellulitis of the right radius135. A nurse is planning care for an adolescent following repair of Meckel diverticulum. Which of the following actions should the nurse include in the plan of care?A. Teach the client about ostomy careB. Administer total parenteral nutritionC. Initiate long term antibiotic therapyD. Maintain an NG tube for decompression136. A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?A. PuritusB. NightmaresC. HyperactivityD. Diplopia25
- A nurse in a community clinic is reviewing the laboratory results of four clients. The nurse should identify that which of the following sexually transmitted infections is nationally notifiable?A. Genital herpes simplex virusB. Bacterial vaginosis trichomoniasisC. GonorrheaD. Human papilloma virus138. A nurse is assessing a toddler who is 8 hours postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?A. Bilateral cool extremitiesB. Serum glucose 90 mg/dLC. Blood pressure 102/58 mm HgD. Weak pedal pulse distal to the site139. A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter. Which of the following actions should the nurse plan to take?A. Gently rub the cream into the skinB. Wash the site with alcohol prior to applying the creamC. Apply the cream 1 hour before the procedureD. Avoid removing the cream prior to the procedure140. A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12-month-old infant. Which of the following actions should the nurse plan to take?A. Change the IV site every 3 daysB. Start the IV in the infant’s footC. Use a 24-gauge catheter to start the IVD. Cover the insertion site with an opaque dressing141. A nurse is teaching a parent about home interventions for a preschooler who is experiencing night terrors. Which of the following instructions should the nurse include in the teaching?A. Allow your child to watch an animated movie right before bedtimeB. Wait until your child indicates that he is tired before putting him to bedC. Avoid allowing your child to sleep in your bedD. Wake your child up during the night terror26
- A nurse is educating an adolescent following the application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?A. I will sprinkle baby powder into the cast if my arm itchesB. I should expect my fingers to be swollen for several daysC. I will elevate my broken arm on pillows at nightD. I should limit the use of the fingers of my broken arm143. A nurse is providing teaching to the parents of a toddler who is to undergo a sweat chloride test. Which of the following statements should the nurse include?A. The purpose of the test is to determine if your child has Crohn’s diseaseB. The technician will use a device to produce an electrical current during the testC. During the test, your child will be in a room that is coldD. Your child’s sweat will be collected over 24 hours144. A nurse is caring for a preschooler who is post-operative following a tonsillectomy. The child is now ready to resume oral intake which of the following dietary choices should the nurse offer the child?A. Sugar-free cherry gelatinB. Vanilla ice creamC. Chocolate milkD. Lime flavored ice pop145. A nurse is preparing a school-age child for an invasive procedure. Which of the following actions should the nurse plan to take?A. Plan for 30-minute teaching session about the procedureB. Use vague language to describe the procedureC. Explain the procedure to the child when they are in the playroomD. Demonstrate deep breathing and counting exercises146. A nurse is caring for a child who has hyponatremia. Which of the following findings should the nurse expect?A. TetanyB. Weight gainC. Elevated heart rateD. Excessive diaphoresis147. A nurse is planning care for a school-age child who is admitted from the emergency department 12-hours-ago. Which of the following interventions should the nurse include to promote adequate sleep for the child?A. Provide the child with video games prior to bedtime to reduce stress27
B. Allow the child to adjust their bedtime to promote autonomyC. Leave the lights on in the child’s room to promote safetyD. Follow the child’s home sleep routine to reduce anxiety148. A nurse is caring for an infant who receives intermittent enteral feeding through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (SATA)A. Offer the infant a pacifier during readingsB. Formula to 39 C (102 F) prior to administrationC. Check for residual volume by aspirating stomach contentsD. Instill the formula over a period of 30 to 45 minutes149. A nurse is providing teaching to the guardian of a school-age child who has sickle cell disease about management of the illness. Which of the following instructions shouldthe nurse include?A. Apply cold compress to painful areasB. But I shall wear a surgical mask to schoolC. Encourage physical activity as toleratedD. Offer fluids of bedtime150. A nurse is discussing coping mechanism with a parent of a three-month-old infant which of the following therapeutic questions should the nurse ask the parent?A. What do you do when your infant is fussy?B. Are you willing to take a new parenting classes?C. Does parenting cause you stress?D. Is it overwhelming when your infant is having a bad day?151. A nurse is reviewing the medical record of a child with cystic fibrosis which of thefollowing should the nurse report to the provider? Click the exhibit button for additional information about the client.A. Heart rateB. HbA1cC. Oxygen saturationD. WBC 48152. A nurse is assessing an infant who has intussusception. Which of the following findings should the nurse expect?A. Sausage-shaped abdominal massB. Board like abdomenC. ConstipationD. Increased urinary output28 - A nurse is caring for a 14-year-old adolescent who has a cast on the right arm andswelling of their right hand. The nurse elevates the adolescents affected extremity. The nurse should identify that which of the following findings is an indication that the intervention has been effective?A. The adolescent report of the cast feels tightB. The adolescent hands feel cool to touchC. The adolescent is able to move their fingers freelyD. The adolescent reports feeling tingling in their arms154. A nurse is planning care for a school-age child who has a new diagnosis of Legg calve perthes disease. Which of the following interventions should the nurse include in the plan of care?A. Instruct a child to perform weight bearing exercisesB. Explain to the child that the disease will last 3 to 6 monthsC. Encourage the guardian to keep their child home from school for one monthD. Administer ibuprofen to the child for discomfort155. A nurse is caring for a two-year-old who has cystic fibrosis and is being discharge from the hospital. The nurse should ensure that which of the following pieces of equipment is available for the child’s home?A. Steam vaporizerB. Suction machineC. Continuous positive airway pressure machineD. High frequency chest compression vest156. A nurse is providing teaching for the parent of a child who has measles. Which of the following information should the nurse include?A. Bathe the child using tepid waterB. Remove loose crust from the lesionsC. Give the child aspirin for a feverD. Withhold live vaccines for 3 months157. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect?A. SteatorrheaB. RhinorrheaC. Weight gainD. Visible peristalsis29
- A nurse is planning to administer diphenhydramine 1.25 mg/kg IV to a school-agechild who weighs 55lb. available is diphenhydramine 50 mg/mL. how many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero that applies. Do not use a trailing zero).Answer: 0.6 mL30