2022 HESI Pediatric (PEDS) RN Exit Exam: V1 & V2
1. The nurse is assessing a 9 year old boy who has been admitted to the hospital with possible
acute postertreptococcal glomerulonephritis (APSGN). In obtaining his history, What
information is most significant?
A. A sore throat last week
B. A history of hypertension
C. Diuresis during the night
D. Back pain for a few days
Answer: A. A sore throat last week
2. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month old infant,
and notes that the FOC has increased 5 inches (12.7 cm) since birth and the child’s head
appears large in relation to body size. Which action is most important for the nurse to take
next?
A. Plot the measurement on the infant’s growth chart
B. Observe the infant for sunset eyes
C. Measure the infant’s head to heel length
D. Palpate the anterior fontanel for tension and bulging
Answer: D. Palpate the anterior fontanel for tension and bulging
3. A female infant recently admitted with vomiting and diarrhoea now weights 10kg. Her
weight at a previous well baby visit was 11 kg. What is the percentage of body weight loss
for this infant?
A. 4%
B. 9%
C. 10%
D. 5%
Answer: B. 9%
4. A male high school student with type 1 diabetes test his blood glucose level before playing
a game of soccer, and he obtains a reading of 18mg/dL (10 mmol/L). Based on this reading,
which action should the nurse take?
A. Tell him to eat a sandwich and fruit before beginning the game
B. Check his urine for ketones
C. Give him permission to go ahead and play soccer
D. Call the healthcare provider
Answer: A. Tell him to eat a sandwich and fruit before beginning the game
5. A 7-year old child is admitted to the hospital with a diagnosis of acute rhematic fever. In
obtaining a health history from the child’s mother, the recent occurrence of which illness is
most significant?
A. Sore throat
B. Chickenpox
C. Mumps
D. Influenza
Answer: A. Sore throat
6. A mother brings her 2 month old son to the clinic for a well-baby exam. During the
assessment the nurse finds that the right testicle is not descended into the scrotum but the left
is palpable. Which action should the nurse take?
A. Prepare to obtain a catheterized urine specimen for culture.
B. Address possible concerns about the child’s future fertility.
C. Ask if the right testis has been seen the scrotum before.
D. Schedule an IV pyelogram to validate presence of testicle.
Answer: C. Ask if the right testis has been seen the scrotum before.
7. The nurse is assessing a 6-month-old infant. Which response requires further evaluation by
the nurse?
A. Has doubled birth weight
B. Turns head to locate sound.
C. Plays “peek-a-boo.”
D. Demonstrates startle reflex.
Answer: D. Demonstrates startle reflex.
8. A 4-year-old girl returns to the pediatrician’s office for a postoperative visit following
hospitalization for minor surgery. When observing the child in the waiting area, which
behavior should the nurse consider normal for this age child?
A. Ignores other children in the play area.
B. Draws picture of self with facial features.
C. “Talks” to an imaginary friend.
D. Sits quietly in her mother’s lap.
Answer: C. “Talks” to an imaginary friend.
9. A preschool-aged child is experiencing respiratory distress is brought to the emergency
department by the parents. The child is anxious, has a temperature of 102.8°F (39.3°C), and is
drooling from the mouth while learning forward when sitting. Which action should the nurse
prepare the child for next?
A. Obtain bedside trays for Intubation or tracheotomy by the healthcare provider.
B. Begin prescribed intravenous antibiotic administration.
C. Provide a nebulizer treatment with bronchodilators.
D. Schedule the child for a stat magnetic resonance imaging (MRI) of the neck.
Answer: A. Obtain bedside trays for Intubation or tracheotomy by the healthcare provider.
10. The nurse is caring for a preschool-aged child with a congenital heart defect who is
admitted with intermittent low-grade fever, fatigue, and weight loss. Further physical
assessment finding include a new murmur, splinter hemorrhages under the nails, and painless
red lesions on the palms of the hands. Which diagnostic procedure should the nurse prepare
the parents to expect the healthcare provider to prescribe?
A. Echocardiogram.
B. Electrocardiogram.
C. Chest radiography.
D. Computerized tomography (CT) scan.
Answer: A. Echocardiogram.
11. A 6-year-old male with a body mass index (BMI) in the 95th percentile for gender and age
arrives at the clinic after a referral from the school nurse. His laboratory findings include
hemoglobin A1c of 5.5% (0.06), blood pressure (BP) in the 50th percentage for age, height in
the 75th percentile, and an LDL cholesterol of 90 mg/dL. (2.33 mmol/L.) Which lifestyle
modification should the nurse discuss with the parents?
A. Recommend increasing daily fruits and vegetables and daily exercise.
B. Return in one month for another evaluation of serum lipids and blood pressure
C. Instruct the parents to weigh the child weekly and measure his BP daily.
D. See a healthcare provider to further assess for diabetes and hypertension.
Answer: A. Recommend increasing daily fruits and vegetables and daily exercise.
12. When administering indomethacin to a premature infant who has patient ductus
arteriosus, the nurse should anticipate which outcome?
A. Decreased urinary output
B. Decreased cardiac murmur
C. Increased number of red blood cells
D. Increased respiratory effort
Answer: B. Decreased cardiac murmur
13. A 2 year old boy who had hypospadias repair yesterday goes to the hospital playroom
with his mother. Which activity should the nurse recommend?
A. Peddling a tricycle in the hall
B. Riding a rocking horse
C. Using a large piece puzzle
D. Playing catch ball with others
Answer: C. Using a large piece puzzle
14. A male child is being prepared for a computed tomography (CT) scan when he begins to
have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down.
What actions should the nurse take? (Select all that apply)
A. Administer an anticonvulsant medication
B. Place pillows inside the side rails
C. Ask the mother to release the child
D. Close blinds room so is darkened
E. Monitor the child’s airway and tongue
Answer: B. Place pillows inside the side rails
C. Ask the mother to release the child
E. Monitor the child’s airway and tongue
15. A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that
her child is irritable, refused to eat and has skin peeling on both hands and feet. Which
intervention should the nurse instruct the mother to implement first?
A. Place the child in a quiet environment
B. Apply lotion to hands and feet
C. Make a list of foods that the child likes
D. Encourage the parents rest when possible
Answer: A. Place the child in a quiet environment
16. The nurse is caring for a school age child who has laboratory results that reveal the
presence of anti-gliadin and anti-endomysial immunoglobulin G and immunoglobulin A
antibodies. The nurse should identify with the parent and child which food to avoid after
discharge to home?
A. Swiss cheese
B. Sweet potatoes
C. Orange Juice
D. Wheat bread
Answer: D. Wheat bread
17. The nurse is giving an intramuscular injection of an antibiotic to a 16-month old toddler
with pneumonia. The toddler does not have any known allergies and has been walking
without assistance for one month. Which technique should the nurse select for
administration?
A. Use a needle length of ½ inch (1.25 cm) to avoid deep tissue damage
B. Administer the injection into the middle of the lateral aspect of the thigh
C. Given in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process
D. Divide the gluteal area into quarters and given IM into the upper outer quadrant
Answer: B. Administer the injection into the middle of the lateral aspect of the thigh
18. While administering the final dose of oral amoxicillin to a preschool-aged boy, he tells the
nurse that this throat hurts. Which intervention is most important for the nurse to implement?
A. Document the child’s comments
B. Inspect the child’s oropharynx
C. Review the child’s history of sore throats
D. Asses skin for signs of allergic reaction
Answer: B. Inspect the child’s oropharynx
19. The mother of a 14-month old tells the nurse that she feeds her child mothering but
prepared toddle foods and feels they provide the best nutrition for her child, but is concerned
about the cost. How should the nurse respond?
A. Teach the mother how to develop a budget to allow her to continue to provide the needed
prepared toddler foods
B. Advise the mother that these foods will only be needed until the growth spurt of the
toddler years is complete
C. Reassure the mother that beginning to replace prepared foods with table foods can provide
the needed nutrients
D. Affirm that these prepared foods are the best way to ensure that the toddler gets all the
needed nutrients
Answer: C. Reassure the mother that beginning to replace prepared foods with table foods
can provide the needed nutrients
20. Which nursing intervention is most important to assist in detecting hypopituitarism and
hyperpituitarism in children?
A. Assessing for behavioral problems at home and school by interviewing the parents
B. Performing head circumference measurements on infants under one year of age
C. Nothing a marked weight gain without a gain in height on a growth chart
D. Carefully recording the height and weight of children to detect inappropriate growth rates
Answer: D. Carefully recording the height and weight of children to detect inappropriate
growth rates
21. The nurse is communicating with a 12-year old who is hearing impaired. Which action is
best for the nurse to use when attempting to communicate with this child?
A. Use a picture board to communicate needs
B. Convey ideas by writing short sentences
C. Attract the child’s attention before speaking
D. Emphasize emotions with facial expressions
Answer: D. Emphasize emotions with facial expressions
22. During the physical exam of an 11-year old girl, the nurse observes budding breasts and
scan public hair. Which Tanner stage should the nurse choose when documenting these
findings?
A. V
B. II
C. III
D. IV
Answer: C. III
23. A 9-year old with leukemia is admitted with a ruptured appendix. A nasogastric tube is
inserted and attached to low intermittent suction. Which finding is most important for the
nurse to the healthcare provider?
A. Increased blood urea nitrogen (BUN)
B. Urinary output of 60 mL/hour
C. Gastric output of 450mL in last 24 hour
D. Absolute neutrophil count of 400/mm3 (4 × 109/L)
Answer: D. Absolute neutrophil count of 400/mm3 (4 × 109/L)
24. A 2-year old child with heart failure (HF) is admitted for replacement of a graft for
coarctation of the aorta. Prior to administering the next dose of digoxin, the nurse obtains an
apical heart rate of 128 beats/minute. What action should the nurse implement?
A. Calculate the safe dose range
B. Administer the schedules dose
C. Review the serum digoxin level
D. Determine the pulse deficit
Answer: B. Administer the schedules dose
25. A mother brings her preteen daughters to the clinic for her first female examination.
During the health assessment the nurse should implement which technique to determine if the
client has reached the age of menarche?
A. Calculate approximate age menstruation should occur
B. Palpate for evidence of temporary gynecomastia
C. Assess for presence of a supernumerary breast nipple
D. Use the Tanner staging to determine sexual maturity
Answer: D. Use the Tanner staging to determine sexual maturity
26. The nurse is administering a nebulized albuterol treatment to a young girl who is having
an asthmatic exacerbation. The client is unable to hold her lips tightly around the mouthpiece.
Which intervention should the nurse implement?
A. Encourage the child to keep a tight seal
B. Allow the treatment to blow in the face
C. Replace the mouthpiece with a mask
D. Decrease the nebulizer air flow rate
Answer: C. Replace the mouthpiece with a mask
27. A breast feeding infant, screened for congential hypothyroidism, is found to have low
levels of thyroidine (T4) and high levels of thyroid stimulating hormone (TSH). What is the
best explanation for this finding?
A. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
B. The thyroxine level is low because the TSH level is high
C. The TSH is high because of low production of T4 by the thyroid
D. High thyroxine levels normally occur in breastfeeding infants
Answer: C. The TSH is high because of low production of T4 by the thyroid
28. The nurse is caring for a child with sickle cell disease who is experiencing a sickle crisis.
Which finding should the nurse report to the healthcare provider immediately?
A. Swelling in the hands or feet
B. Jaundice
C. Ulcers on the legs
D. Chest pain
Answer: B. Jaundice
30. An adolescent with seasonal allergies, asthma and eczema is obtaining a physical and
medical clearance for an overnight week long summer camp which action should the nurse
prioritize?
A. Ensure the client can perform a return demonstration of sunscreen applicate
B. Remind to pack a rescue inhales with adequate doses of medication
C. Advise to balance camp activities with rest and stay well hydrated
D. Validate the camp counsellors credentials for emergency response
Answer: B. Remind to pack a rescue inhales with adequate doses of medication
31. An infant is admitted for surgery who has a wilms’ tumor. Which nursing intervention
should the nurse implement during the pre-operation period?
A. Administer pain medication based on the FACES pain scale
B. Include the prone position in the q2h turning schedule
C. Give antiemetic medications to prevent nausea and vomiting
D. Careful bathing and handling that avoids abdominal manipulation
Answer: D. Careful bathing and handling that avoids abdominal manipulation
33. One week after removing a tick, a student arrives at the school nurse’s office with report
of flu-like symptoms. Which intervention should the school nurse implement first?
A. Observe for a rash around the tick bite site
B. Measure the students oral temperature
C. Inform the student of Lyme disease signs and symptoms
D. Instruct the student’s parent to seek medical attention
Answer: D. Instruct the student’s parent to seek medical attention
34. A one month old male infant is brought to the clinic by his mother who states that her son
has been vomiting forcefully after each meal for the last three days. The infant is afebrile,
dehydrated and pyloric stenosis is suspected. What other findings should the nurse identify
that are consistent with pyloric stenosis?
A. Perianal diaper rash from persistent diarrhea
B. Rooting, hunger and irritability
C. An olive-shaped mass in the abdominal area
D. Bile-stained emesis
Answer: C. An olive-shaped mass in the abdominal area
35. The school nurse is assessing a child who reports having an itchy scalp. The nurse has
sent home care instructions capills for several children in the school. Which assessment
should the nurse implement to this child?
A. Determine if silvery crusty scales are seen in skin folds
B. Inspect hair follicle shafts for adherence of nits
C. Observe base of neck and forehead for ring shaped rash
D. Look for raised, reddened areas and balding on scalp
Answer: B. Inspect hair follicle shafts for adherence of nits
36. The nurse plans to conduct a physical assessment of a toddle. Which protocol is best for
the nurse to implement?
A. Ensure that the room is warm and undress the child completely
B. Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal
of clothing
C. Have the parent remove the child’s outer clothing and remove the diaper or training pants
when necessary
D. Help the child take off his/her clothes. Removing underwear only to conduct examination
of the genitalia
Answer: B. Prior to helping the child remove his/her clothing, use a paper doll to
demonstrate removal of clothing
37. During a well-baby clinic visit the mother of a 6 month old infant asks the nurse is she
can have a prescription for Poly VI sol with fluoride. Though the infant is still feeding the
mother provides the child with supplemental formula feeding. Which assessment is most
important for the nurse to obtain?
A. The newborn’s gestational age assessment
B. Weight gain and type of formula taken daily
C. Water source used with supplement feedings
D. The infant’s current hemoglobin and hematocrit
Answer: C. Water source used with supplement feedings
38. The nurse is performing a routine assessment of a 3 year old at a community heath center.
Which behavior by the child should alert the nurse to request a follow up for a possible
autistic, spectrum disorder (ASD)?
A. Perform odd repetitive behaviors
B. Stroke the hair of a hand held doll
C. Has a history of temper tantrums
D. Shows indifference to verbal stimulation
Answer: B. Stroke the hair of a hand held doll
39. The mother of an 11 year old boy who has juvenile idlopathic arthritis tells the nurse, “I
really don’t want my son to become dependent on pain medication, so I only allow him to
take it when he is really hurting” which information is most important for the nurse to
provide this mother?
A. Encourage quiet activities such as watching television as a pin distracter
B. The use of hot baths can be used as an alternative for pain medication
C. The child should be encouraged to rest when he experiences pain
D. Giving pain medication around the check helps control the pain
Answer: D. Giving pain medication around the check helps control the pain
41. A 3-year-old child with HIV infection is staying with a foster family who is caring for
three other foster children in their home. When one of the children acquires pertussis, the
foster parent calls the clinic and asks the nurse with they should do. Which action should the
nurse take first?
A. Review immunization records of the child with an HIV infection.
B. Place the child with an HIV infection in a protective environment.
C. Report the exposure of the child with HIV to the Health Department.
D. Remove the child with an HIV infection from the foster home.
Answer: A. Review immunization records of the child with an HIV infection.
42. A 6-month-old, diagnosed with short bowel syndrome, began enteral feeding yesterday.
To maintain normal growth and development of the child during this period, what action
should the nurse include in the infant’s plan of care?
A. Give the infant a pacifier during feedings.
B. Use sterile technique during feedings.
C. Speak to the healthcare provider about instituting physical therapy.
D. Ensure placement of the nasogastric tube with an abdominal x-ray.
Answer: A. Give the infant a pacifier during feedings.
43. The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) ask,
“How can our son have this disease? We are wondering if we should have any more
children.” Which information should the nurse provide to these parents?
A. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in
their mothers.
B. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening
the muscles.
C. The male infant had a viral infection that went unnoticed and untreated, so muscle damage
was incurred.
D. This is an inherited X-linked recessive disorder, which primarily affects male children in
the family.
Answer: D. This is an inherited X-linked recessive disorder, which primarily affects male
children in the family.
44. A 9-year-old with celiac disease is admitted to the pediatric unit following an
appendectomy. Which food should the nurse remove from this child’s meal tray?
A. Fruit cup.
B. Crackers.
C. Turkey.
D. Chicken rice soup.
Answer: B. Crackers.
48. The nurse is preparing a 10-year-old child for suturing of a lacerated forehead. Both
parents and a 12-year-old sibling are at the child’s bedside. Which instruction best supports
this family?
A. It is best if the sibling goes to the waiting room until the suturing is completed.
B. All of you should leave while the healthcare provider sutures the child’s forehead.
C. While waiting for the healthcare provider, only one visitor may stay with the child.
D. Please decide who will stay when the healthcare provider begins suturing.
Answer: D. Please decide who will stay when the healthcare provider begins suturing.
49. A male infant is admitted to the pediatric unit with pertussis and is exhibiting a
“whooping-like cough.” The mother brings the infant to the nurses’ station to seek assistance.
Which intervention should the nurse implement first?
A. Explain the need to maintain droplet precautions to prevent spread to others on the unit.
B. Give the infant and oral dose of a prescribed antitussive and analgesic/antipyretic.
C. Cover the infant’s mouth and assist the mother to take the infant back to the room.
D. Ask the mother if the cool mist humidifier at the beside is functioning and releasing mist.
Answer: C. Cover the infant’s mouth and assist the mother to take the infant back to the
room.
51. The caregiver of a preschooler learns about long-term endocrine dysfunctions resulting
from their child’s craniospinal radiation. Which statement made by the caregiver should the
nurse recognize as needing additional education?
A. Follow up at a dentist routinely to monitor for delayed tooth eruption.
B. Make plans for growth hormone injections to enhance growth.
C. Onset of cold intolerance and dry skin may indicate a problem.
D. Development of secondary sex characteristics may be slower.
Answer: B. Make plans for growth hormone injections to enhance growth.
53. A nurse is teaching a class for mothers of premature infants, and is asked about “a shot for
respiratory virus.” What information about palivizumab is correct?
A. It must be repeated every two months to be effective.
B. It is recommended for infants who meet established high-risk criteria.
C. It is a required immunization for all infants under the age of 3 months.
D. It provides protection for one year with a single injection.
Answer: B. It is recommended for infants who meet established high-risk criteria.
54. A 10-year-old girl is diagnosed with inflammatory bowel disease (IBD). Her mother is
concerned that she will experience development delays as the result of this disorder. How
should the nurse respond?
A. Growth failure is a concern, but developmental delays are not likely to occur.
B. Scheduling a private tutor can help to prevent developmental delays.
C. She will only experience developmental delays if weight loss cannot be controlled.
D. She is at high risk for a number of different problems, including developmental delays.
Answer: A. Growth failure is a concern, but developmental delays are not likely to occur.
2022 HESI Pediatric (PEDS) RN Exam
1. The nurse is caring for a 3-year-old child who is 2 hours postop from a cardiac
catheterization via the right femoral artery. Which assessment finding is an indication of
arterial obstruction?
Answer: Right foot is cool to the touch and appears pale and blanched
2. An infant with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action
should the nurse implement first?
Answer: Place the infant in a knee- chest position
3. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The
nurse determines that the increased respiratory rate is a compensatory mechanism for which
acid base alteration?
Answer: Metabolic Acidosis
4. Patient with diarrhea for 3 days – what does this cause?
Answer: Metabolic Alkalosis?
5. Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell
anemia understands dietary considerations related to the disease?
Answer: Lemonade
6. The HR for a 3-year-old with CHF has steadily decreased over the last few hours, now is
76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be
reported immediately to a health care provider?
Answer: BP 70/40
7. 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is
scheduled. Which information should the nurse provide this child concerning the procedure?
Answer: Describe he side-lying, knees to chest position that must be assumed during the
procedure
8. Patient has low platelets.
Answer: Bleeding precaution
9. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological
mechanism is the most likely consequence of this infant's clinical picture?
Answer: Metabolic Alkalosis
10. A month old girl is brought to the clinic by her mother because she has had a cold for 2 to
3 days and woke up this morning with a hacking cough and difficulty breathing. Which
additional assessment finding should alert the nurse that the child is in acute respiratory
distress?
Answer: Flaring of the nares
11. During a well-baby visit the parents explain that the soft bulge appears in the groin of
their 4 month old son when he cries or strains with stool. The infant is scheduled for surgical
repair of the inguinal hernia in 2 weeks. The parent should be instructed to take which
measure if the hernia becomes incarcerated prior to surgery?
Answer: Gently manipulate the hernia for reduction
12. The nurse is developing the plan of care for a hospitalized child with von Willebrand
disease. What priority nursing intervention should be included in this child’s plan of care?
Answer: Guard against bleeding injuries
13. How should then nurse instruct the parents of a 4-month-old with seborrheic dermatitis
(cradle cap) to shampoo the child’s hair?
Answer: use a soft brush and gently scrub the area
14. The mother of a one-month-old calls the clinic to report that the back of her infant’s head
is flat. How should the nurse respond?
Answer: Position the infant on the stomach occasionally when awake and active
15. A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When
obtaining the nursing history which finding should the nurse expect to obtain?
Answer: A recent strep throat infection
16. In assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most
for the nurse to obtain?
Answer: recent recurrence of infection
17. A mother brings her 8-month-old baby boy to the clinic because he has been vomiting and
had diarrhea for the last 3 days. Which assessment is more important for the nurse to make?
Answer: Measure the infant's pulse.
18. Following admission for a cardiac catheterization, the nurse is providing discharge
teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. What instruction
should the nurse give the parents if their child becomes pale, cool, and lethargic?
Answer: Contact their healthcare provider immediately.
19. A mother brings her 2-year-old son to the clinic because he has been crying and pulling
on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F. Which
intervention should the nurse implement?
Answer: Ask the mother if the child has had a runny nose
20. During a follow-up clinical visit a mother tells the nurse that her 5-month-old son who
had surgical correction for Tetralogy of Fallot has rapid breathing, often takes a long time to
eat, and requires frequent rest periods. The infant is not crying while being held and his
growth is in the expected range. Which intervention should the nurse implement?
Answer: Auscultate heart and lungs while infant is held.
21. An adolescent's mother calls the primary HCP's office to inquire about the results of her
daughter's serum test results that were drawn last week. Since it is the teenager's 18th
birthday, how should the nurse respond to this mother's inquiry?
Answer: Explain that the information cannot be released without the 18-year old’s
permission
22. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment
finding indicates to the nurse that the medication is having the desired effect?
Answer: Reduction of edema
23. An infant with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which
action should the nurse implement first?
Answer: Place the infant in a knee- chest position
24. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health nurse notes that the child has developed episodes
of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most
important for the nurse to take?
Answer: Change to latex-free gloves when handling infant
25. The nurse is examining an infant for possible cryptorchidism. Which exam technique
should be used?
Answer: Place the infant in a warm room and use a calm approach
26. In caring for an client with acute epiglottitis, which nursing action takes priority?
Answer: Prepare for endotracheal intubation
27. A toddler with hemophilia is being discharged from the hospital. Which teaching should
the nurse include in the discharge instructions to the mother?
Answer: Apply padding on the sharp corners of the furniture
28. When caring for a child sickle cell disease, the nurse knows that the child will most likely
exhibit which sign when experiencing a sickle cell crisis?
Answer: Pain
29. The nurse is administering an oral medication to a reluctant preschool-age boy. Which
intervention should the nurse implement?
Answer: Use straightforward approach with the child
30. The nurse is planning care for a newborn infant scheduled for a cardiac catheterization.
Which occurrence poses the greatest risk for this child?
Answer: Acute hemorrhage from the entry site of the catheter after the procedure
31. A mother brings her 2-year-old son to the clinic because he has been crying and pulling
on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F (38 C). Which
intervention should the nurse implement?
Answer: Ask the mother if the child has had a runny nose
32. The parents of a 4 week-old infant phone the pediatric clinic to report that their infant eats
well but vomits after each feeding. To differentiate between normal regurgitation and pyloric
stenosis, which information is most important for the nurse to obtain?
Answer: Degree of forcefulness of vomiting episodes
33. The teacher notifies the school nurse that a child's nose is bleeding for no apparent reason.
What action should the nurse implement first?
Answer: Pinch the nose using thumb and finger for 10 minutes
34. A hospitalized child stiffens and stars to seize as the nurse enters the room. What actions
should the nurse take? (Select all apply)
Answer: • Turn client to the side if possible
• Pad side rails with available pillows and blankets
• Monitor duration and progress of the seizure
35. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea
(sudden aimless movements of the arms and legs). Which information should the nurse
provide to the parents?
Answer: The chorea or movements are temporary and will eventually disappear
36. A 9-year-old boy is diagnosed with diabetes mellitus Type 1. Which stage of Erikson's
theory of psychosocial development is the nurse addressing when teaching this client about
insulin injections?
Answer: Industry
37. The nurse is assessing an 8-month-old who has a cough, axillary temperature of 100 F,
and rhinorrhea. What information is most important for the nurse to obtain from this child's
mother?
Answer: Immunization status of the infant
38. A breast-feeding mother returns to work when her infant is 5 months old. She is having
difficulty pumping enough milk to meet her infant's dietary requirements. Which suggestion
should the nurse provide to this mother?
Answer: Supplement with an iron-rich formula
39. A child with possible Duchenne muscular dystrophy (DMD) undergoes an
electromyogram (EMG). Following the procedure, the child's parents tell the nurse that the
child is complaining of sore muscle. How should the nurse respond?
Answer: Offer reassurance that muscle soreness following these procedures is temporary and
does not indicate a problem
40. The heart rate for a 3-year-old with a congenital heart defect has steadily decreased over
the last few hours and is now at 76 beats/minute; the previous reading 4 hours ago was 110
beats/minute. Which additional clinical finding should be reported immediately to the
healthcare provider?
Answer: Blood pressure of 70/40
41. A 12-year-old is admitted to the hospital with possible encephalitis, and a lumbar
puncture is schedule. Which information should the nurse provide concerning to this
procedure?
Answer: Describe the side-lying, knee to the chest position that must be assumed during the
procedure
42. A child who has been vomiting for 3 days is admitted for correction of fluid and
electrolyte imbalances. What acid base imbalance is this child likely to exhibit?
Answer: Metabolic alkalosis
43. Several children at a day camp return from playing in a tick-infested field. What action
should the camp nurse take first?
Answer: Observe the children's skin for attached ticks.
44. An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14
days of taking levofloxacin (Levaquin) 500 mg orally once daily and metronidazole (Flagyl)
500 mg twice daily. She asks the nurse, "Why do I have to be in the hospital? Why can't I get
my treatment at home?" Which purpose should the nurse provide that supports and effective
outcome?
Answer: Administration of a supervised parenteral antibiotic protocol
45. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic
ketoacidosis (DKA). Which action is most important for the nurse to include in the child's
plan of care?
Answer: Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin
R).
46. A 6-month-old, diagnosed with short bowel syndrome, began enteral feedings yesterday.
To maintain normal growth and development of the child during this period, what action
should the nurse include in the infant's plan of care?
Answer: Give the infant a pacifier during feeding
47. The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac
disease). Choosing which food indicates that the teaching has been effective?
Answer: Rice
48. While teaching a parenting class to new parents the nurse describes the needs of infants
and toddlers regarding discipline and limit setting. What is the most important reason for
implementing such parenting behaviors?
Answer: They provide the child with a sense of security
49. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What
suggestion should the nurse provide?
Answer: Use a barrier cream, such as zinc oxide, which does not have to be completely
removed with each diaper change.
50. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other
foster children in their home. When one of the children acquires pertussis, the foster mother
calls the clinic and asks the nurse what she should do. Which action should the nurse take
first?
Answer: Review the immunization documentation of the child who has HIV
51. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis "altered
nutrition, less those body requirements related to anorexia, nausea and vomiting" is
identified. Which intervention the nurse included in this child plan of care?
Answer: Allow the child to eat any food desired and tolerated
52. Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest
physiotherapy (CPT) that they will perform for their child at home. Which action?
Answer: Percussion and postural drainage.
53. The nurse plans to screen only the highest risk children for scoliosis. Which group of
children should the nurse screen first?
Answer: Girls between ages 10 and 14
54. A mother brings her 8 mo. old baby boy to clinic because he has been vomiting and had
diarrhea for last 3 days. Which assessment is most important for nurse to make?
Answer: Measure the infant's pulse
55. Nurse gets a call from a mother of a 10 y/o that just returned from camp with expanding
circular red rash on arm. Mom asks what over the counter product is safe to use. How should
the nurse respond?
Answer: Explain need for immediate exam
