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. Decrease the Child’s sodium intake
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 to take which of the following actions during a seizure?
A. Minimize movement of the limbs
B. Insert a tongue blade between the teeth
C. Clear the area of hard object
D. Place the child in a prone position
C. Clear the area of hard object
B. Apply warm compresses to the affected areas
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 can drink milk on an empty stomach.
B. You should consume flavored yogurt instead of plain yogurt.
C. You can tolerate plain milk better than chocolate milk.
D. You can replace milk with nondairy source of calcium
D. You can replace milk with nondairy source of calcium
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. Urine output of 15 mL in the last 2 hr – urine output should = 1mL/kg/hr =>24mL
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. I will steam carrots and cut them into small pieces for her.”
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. Your child will be on a gluten-free diet for the rest of her life.”
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%
C. Intercoastal retractions
D. Elevated heart rate
A nurse is caring for a school-age child who is 1 hr postoperative following it tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)
A. Administer an analgesic to the child on a scheduled basis.
B. Observe the child for frequent swallowing
C. Provide cranberry juice to the child.
D. Maintained a child in supine position.
E. Discourage the child from coughing
A. Tachycardia
D. Dyspnea
E. Bounding peripheral pulses
A nurse caring for a toddler who is in the terminal stage of neuroblastoma. The parents ask, how can we help our child now? Which of the following responses by the nurse is appropriate?
A. Talk to your child about the meaning of death.”
B. Encourage your child’s friends to visit.”
C. Stay close to your child.”
D. Change your child’s schedule every day.”
C. “Stay close to your child.”
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
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. Consume 1,500 to 1,700 calories per day.”
B. Decrease your vitamin D intake once you start to menstruate.”
C. Increase the amount of your dietary iron intake.”
D. Limit your sodium intake to 3,000 grams per day.”
C. ‘Increase the amount of your dietary iron intake.”
A nurse is preparing to administer immunization 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. Inject the immunizations into the deltoid muscle
C. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
D. Use a 20-gauge needle for the injections.
A. Provide a pacifier coated with an oral sucrose solution prior to the injections.
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. Initiate contact isolation precautions.
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. “I will give my child pancreatic enzymes with snacks and meals.”
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
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. I will increase my intake of vitamin 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. Provide humidified oxygen via nasal cannula.
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. Administer as acyclovir PO two times per day.
B. Soak hairbrushes in boiling water for 10 minutes
C. Apply bactericidal ointment to lesions.
D. Seals soft toys in a plastic bag for 14 days.
C. Apply bactericidal ointment to lesions.
B. Increased antistreptolysin O titer (ASO)
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. Oral opioid doses should be larger than parenteral doses –
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. Administer total parenteral nutrition.
B. Teach the client about ostomy care.
C. Initiate long-term antibiotic therapy.
D. Maintain an NG tube for decompression.
D. Maintain an NG tube for decompression.
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
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. Observe the child’s throat with a flashlight.
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. Clean the gums with Saline soaked gauze.
B. Administer oral viscous lidocaine.
C. Schedule routine oral care every 8 hr.
D. Moisten the mucosa with lemon glycerin swabs
A. Clean the gums with Saline soaked gauze.
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.
A. Change the chest tube insertion site dressing every 12 hr.
A nurse is prioritizing care for 4 clients. Which of the following clients should the nurse assess 1st?
A. An adolescent who is in skin traction and report a pain level of 7 on a scale from 0 to 10
B. An adolescent who has sickle cell anemia and slurred speech
C. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change.
B. An adolescent who has sickle cell anemia and slurred speech – indicates stroke
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. Give the infant fruit juice between feedings
B. Use half-strength formula when feeding the infant.
C. Keep the infant in a visually stimulating environment.
D. Assign consistent nursing staff to care for the infant.
D. Assign consistent nursing staff to care for the infant
A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden infant death syndrome is (SIDS). Which of the following statements by the parents indicates an understanding
of the teaching?
A. I will move my baby stuffed animal to the corner of her crib while she sleeps.”
B. I will dress my baby in lightweight clothing to sleep.”
C. I will have my baby sleep next to me in bed during the night.”
D. I will lay my baby on her side to sleep for naps.”
B. “I will dress my baby in lightweight clothing to sleep.”
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. Keep the affected extremity straight for at least 6 hr.
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. “we’ll be sure to demonstrate a new skill before expecting our son to perform it .”
A nurse is teaching a parent of a 10-month-old infant about home safety. Which of the following
instructions should the nurse include in the teaching? (Select all that apply.)
A. Remove labels from containers that contain toxic substances
B. Select a toy chest that has a heavy, hanged lid
C. Place gates at the top and bottom of the stairs.
D. Keep toilet lids in the upright position.
E. Ensure the crib mattress is in the lowest position.
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. “I should call my doctor if my child begins vomiting.”
C. Blood pressure 118/74 mm Hg
D. Increased hematocrit – diarrhea indicated dehydration
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. “The bulge can temporarily enlarge when your baby cries.”
D. Perform development testing for delays.
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? (Click on the Exhibit button for
additional information about the client. There are three tabs that contain separate categories of data.)
A. Obtain a rectal temperature every 4 hr.
B. Apply viscous lidocaine to the oral mucosa
C. Place the child in knee-chest position.
D. Initiate bleeding precautions.
D. Initiate bleeding precautions.
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. I will increase the amount of fluids I offer my child.
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. Administer this medication to your child with a dropper
A nurse is caring for an infant who has tetralogy of Fallot and is having a hypercyanotic episode
after crying. Which of the following interventions should the nurse implement?
A. Initiate continuous positive airway pressure.
B. Provide firm stimulation to the infant’s trunk.
C. Place the infant in the knee-chest position.
D. Perform postural drainage.
C. Place the infant in the knee-chest position
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. Apply a warm, moist compress three times per day.”
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 administrating the medication
D. We will repeat the dose if our child vomits shortly after administration.”
A. We will wait to give the medication at the next scheduled time if a dose is missed
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.
C. Remove nits from the child’s hair using a fine
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. Use a trumbling E chart for the assessment.
A. Phytonadione – aka Vitamin K
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. “Tell her that she may have a sandwich or soup for lunch.”
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