ATI PEDIATRICS PROCTORED 2019 B EXAM COMPLETE QUESTIONS AND
ANSWERS WITH RATIONALES.LATEST UPDATE 2023
1. A nurse is assessing the pain level of a 3 year old toddler. Which of the following
assessment scales should the nurse use?
A. FACES
B. Numeric
C. CRIES
D. Visual analog
Answer: A.
Rationale:
The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old
and older. This scale allows the toddler to point to the face that depicts their current level of
pain. The nurse can then determine the need for pain management.
2. A nurse is planning an educational program to teach parents about protecting their children
from sunburns. Which of the following instructions should the nurse plan to include?
A. allow your child to play outside during the hours between 10:00am and 2:00pm.
B. "choose a waterproof sunscreen with a minimum SPF of 15."
C. "dress you child in loose weave polyester fabric prior to sun exposure."
D. "reapply sunscreen every 4 hours."
Answer: B.
Rationale:
The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15
for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk
of sunburn.
3. A nurse is performing hearing screenings for children at a community health fair. Which of
the following children should the nurse refer to a provider for a more extensive hearing
evaluation?
A. an 18 month old toddler who has unintelligible speech
B. a 3 month old infant who has exaggerated startle response
C. a 4 year old preschooler who prefers playing with others rather than alone
D. an 8 month old infant who is not yet making babbling sounds
Answer: D.
Rationale:
The nurse should refer an infant who is not making babbling sounds by the age of 7 months
to a provider for a more extensive evaluation of hearing.
4. A nurse in an emergency department is assessing a 3 month old infant who has rotavirus
and is experiencing acute vomiting and diarrhea. Which of the following manifestations
should the nurse identify as an indication that the infant has moderate to severe dehydration?
A. HR 124
B. increased tear production
C. sunken anterior fontanel
D. capillary refill 2 seconds
Answer: C.
Rationale:
The nurse should recognize that a sunken anterior fontanel is an indication of moderate to
severe dehydration due to the acute loss of fluid.
5. A nurse is providing teaching to the family of a school age child who has juvenile
idiopathic arthrisis. Which of the following instructions should the nurse include in the
teaching?
A. "limit movement of the child's large joints"
B. "encourage the child to perform independent self-care."
C. "provide the child with a soft mattress for sleeping."
D. "schedule a 2 hour daily nap for the child in the afternoon."
Answer: B.
Rationale:
The nurse should teach the family the importance of encouraging the child to perform
independent self-care. This will minimize the child's pain while maximizing mobility.
Encouraging and praising the child's efforts for independence will also increase their selfesteem.
6. A nurse is planning care for a school age child who has a tunneled central venous access
device. Which of the following interventions should the nurse include in the plan?
A. use sterile scissors to remove the dressing from the site
B. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use
C. access the site suing a noncoring angle needle
D. use a semipermeable transparent depressing to cover the site
Answer: D.
Rationale:
The nurse should cover the site with a semipermeable transparent dressing to reduce the risk
of infection.
7. A nurse is providing anticipatory guidance to the parent of a toddler. Which of the
following expected behavior characteristics of toddlers should the nurse include?
A. controls impulsive feelings
B. understands right from wrong
C. easily separates from parents for long periods of time
D. expresses likes and dislikes
Answer: D.
Rationale:
The nurse should include that expressing likes and dislikes is an expected behavior of
toddlers. This is the time in life when a toddler is developing autonomy and self-concept.
They will try to assert themselves and frequently refuse to comply. The parent should allow
the child to have some control, but also set limits for them so they learn from their behavior
and learn to control their actions.
8. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema.
Which of the following findings indicates effectiveness of the medication?
A. reports an absence of nausea and vomiting
B. reports experiencing an onset of loose stools within 15 minutes of administration
C. serum potassium level 4.1 mEq/L
D. blood pressure 86/52 mm Hg
Answer: C.
Rationale:
The nurse should monitor the adolescent's serum potassium level following the administration
of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by
exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level
within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the
medication.
9. A nurse is assessing an infant who has pneumonia. Which of the following findings is the
priority for the nurse to report the provider?
A. nasal flaring
B. WBC count 11,300/mm3
C. diarrhea
D. abdominal distension
Answer: A.
Rationale:
When using the airway, breathing, and circulation approach to client care, the nurse should
determine that the priority finding to report to the provider is nasal flaring. Nasal flaring
indicates the infant is experiencing acute respiratory distress.
10. A nurse is providing discharge teaching to the guardian of a school age child who has
undergone a tonsillectomy. Which of the following statements by the guardian indicates an
understanding the teaching?
A. "my child can resume usual activities since this year just an outpatient surgery."
B. "my child will be able to drink the chocolate milkshake I promised to get for them
tonight."
C. "I will notify the doctor if I notice that my child is swallowing frequently."
D. "I will have my child gargle with warm salt water to relieve their sore throat."
Answer: C.
Rationale:
The nurse should instruct the parent that frequent swallowing is an indication of bleeding and,
if it is observed, to notify the provider immediately.
11. A nurse is discussing organ donation with the parents of a school age child who has
sustained brain death due to a bicycle crash. Which of the following actions should the nurse
take first?
A. inform the parents that written consent is required prior to organ donation
B. provide written information to the parents about organ donation
C. ask the provider to explain misconceptions of organ donation to the parents.
D. explore the parents feelings and wishes regarding organ donation
Answer: D.
Rationale:
The first action the nurse should take when using the nursing process is assessment. The
nurse should first explore the parents' feelings and wishes regarding organ donation to assist
in determining if organ donation is the right choice for the family.
12. A nurse is caring for a newly admitted school age child who has hypopituitarism. Which
of the following medications should the nurse expect the provider to prescribe?
A. Desmopressin
B. Luteinizing hormone-releasing hormone
C. Recombinant growth hormone
D. Levothyroxine
Answer: C.
Rationale:
Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell
growth and results in growth failure. The nurse should expect the provider to prescribe this
treatment.
13. A nurse is providing discharge teaching to the parents of a 3 month old infant following a
cheiloplasty. Which of the following instructions should the nurse include?
A. "clean your baby's sutures daily with a mixture of chlorhexidine and water."
B. "expect your baby to swallow more than usual over the next few days."
C. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours."
D. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3
days."
Answer: D.
Rationale:
The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the
infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for
several weeks to promote healing.
14. A nurse is caring for a school age child who has peripheral edema. The nurse should
identify that which of the following assessments should be performed to confirm peripheral
edema?
A. palpate the dorsum of the child's feet
B. weigh the child daily using the same scale
C. assess the child's skin turgor
D. observe the child for periorbital swelling
Answer: A.
Rationale:
The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony
prominence for 5 seconds to assess for peripheral edema.
15. A nurse is caring for a 10 year old child following a head injury. Which of the following
findings should the nurse identify as an indication that the child is developing diabetes
incipidus?
A. urine specific gravity 1.045
B. sodium 155 mEq/L
C. blood glucose 45 mg/dL
D. urine output 35 mL/hr
Answer: B
Rationale:
Diabetes insipidus (DI) is a condition characterized by an imbalance of fluids in the body,
leading to the production of large amounts of dilute urine. It often results from a deficiency of
antidiuretic hormone (ADH) or an insensitivity of the kidneys to ADH. This can occur after a
head injury, which may damage the hypothalamus or pituitary gland where ADH is produced
and released.
16. A school nurse is providing an in service for faculty about improving education for
students who have ADHD. Which of the following statements by a faculty member indicates
an understanding of the teaching?
A. "I will plan to increase the amount of homework I assign to students who have ADHD."
B. I will give students who have ADHD the same amount of time as other students to
complete tests.
C. "I will allow students who have ADHD one rest break throughout the day."
D. "I will teach challenging academic subjects to students who have ADHD in the morning."
Answer: D.
Rationale:
Faculty should plan to teach challenging academic subjects in the morning when students
who have ADHD are most able to focus and their medication is most likely to be effective.
17. A nurse is providing discharge teaching to the parent of an 18 month old toddler who has
dehydration due to acute diarrhea. Which of the following statements by the parent indicates
an understanding of the teaching?
A. "I will offer my child small amounts of fruit juice frequently."
B. "I will avoid giving my child solid foods until the diarrhea has stopped."
C. "I will monitor my child's number of wet diapers."
D. "I will give my child polyethylene glycol daily for 7 days."
Answer: C.
Rationale:
The nurse should teach the parent to closely monitor the child's number of wet diapers.
Monitoring the number of wet diapers per day is an effective way for the parent to monitor
adequate output and hydration status.
18. A nurse is teaching a school age child and their parent about postoperative care following
cardiac catheterization. Which of the following instructions should the nurse include?
A. "Stay home from school for 1 week following the procedure."
B. "follow a diet that is low in fiber for 1 week."
C. "wait 3 days before taking a tub bath."
D. "apply a pressure dressing to the site for 3 days."
Answer: C.
Rationale:
The child should keep the site clean and dry for at least 3 days to reduce the risk of infection.
Tub baths should be avoided for 3 days to avoid immersion of the incision in water.
19. A nurse is planning care to address nutritional needs for a preschooler who has cystic
fibrosis. Which of the following interventions should the nurse include in the plan?
A. administer pancreatic enzymes 2 hours after meals
B. discontinue the use of pancreatic enzymes if steatorrhea develops
C. limit fluid intake to 750 mL per day
D. increase fat content in the child's diet to 40% of total calories.
Answer: D.
Rationale:
A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas
and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake
to 35% to 40% of total caloric intake.
20. A nurse is admitting an infant who has in tusses caption. Which of the following findings
should the nurse expect? (select all that apply)
A. steatorrhea
B. vomiting
C. lethargy
D. constipation
E. weight gain
Answer: B, C.
Rationale:
Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have
bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is
a manifestation of cystic fibrosis. Vomiting is correct. The nurse should expect an infant who
has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of
the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse
should expect an infant who has intussusception to exhibit lethargy due to episodes of severe
pain during which the infant cries inconsolably, leading to exhaustion and decreased
nutritional intake. Constipation is incorrect. The nurse should expect an infant who has
intussusception to have mucus-filled and red jellylike diarrhea due to the leaking of blood and
mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect an infant
who has intussusception to have weight loss due to anorexia and episodes of vomiting and
diarrhea.
21. A nurse is assessing an 8 year old child who has early indications of shock. After
establishing an airway and stabilizing the child's respirations, which of the following actions
should the nurse take next?
A. insert an indwelling urinary catheter
B. measure weight and height
C. initiate IV access
D. maintain ECG monitoring
Answer: C.
Rationale:
After establishing an airway and stabilizing the child's respirations, the next action the nurse
should take when using the airway, breathing, and circulation approach to client care is to
establish IV access to maintain the child's circulatory volume.
22. A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of
the following statements by the adolescent indicates an understanding of the teaching?
A. "I should buy plastic shoes to wear at the swimming pool."
B. "I should wear sandals as much as possible."
C. "I should place the permethrin cream between my toes twice daily."
D. "I should seal my non-washable shoes in plastic bags for a couple of weeks."
Answer: B.
Rationale:
Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the
medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing
sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.
23. A nurse is caring for a school age child who has diabetes mellitus and was admitted with a
diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the
following findings should the nurse expect?
A. deep respirations of 32/min
B. shallow respirations of 10/min
C. paradoxic respirations of 26/min
D. periods of apnea lasting for 20 seconds
Answer: A.
Rationale:
The nurse should expect Kuss- maul respirations in a child who has diabetic ketoacidosis.
These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide
and achieve a state of homeostasis.
24. A nurse is assessing a 6 month old infant during a well child visit. Which of the following
findings should the nurse report to the provider?
A. presence of a central incisor tooth
B. presence of strabismus
C. presence of an open anterior fontanel
D. presence of external cerumen
Answer: B.
Rationale:
Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not
corrected early, this can lead to blindness. Therefore, the nurse should report this finding to
the provider.
25. A charge nurse is preparing to make a room assignment for a newly admitted school age
child. Which of the following considerations is the nurse's priority?
A. length of stay
B. treatment schedule
C. disease process
D. self-care ability
Answer: C.
Rationale:
The transmission of infectious diseases is the greatest risk to this child and other children on
the unit. Therefore, the child's disease process is the nurse's priority consideration.
26. A school nurse is caring for a child following a tonic-clonic seizure. Which of the
following actions should the nurse take first?
A. check the child for a head injury
B. observe for oral bleeding
C. check the child's respiratory rate
D. observe for extremity weakness
Answer: C
Rationale:
Primary Assessment is the child's respiratory status is critical as tonic-clonic seizures can lead
to respiratory compromise. Ensuring the child is breathing adequately is essential to prevent
hypoxia and other complications.
27. A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree
C (104 degrees F). After administering acetaminophen, which of the following actions should
the nurse plan to take to reduce the toddler's temperature?
A. apply a cooling blanket to the toddler
B. dress the toddler in minimal clothing
C. give the toddler a tepid bath
D. administer diphenhydramine to the toddler
Answer: B.
Rationale:
The nurse should recognize that dressing the toddler in minimal clothing will expose the skin
to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.
28. A nurse is creating a plan of care for a newly admitted adolescent who has bacterial
meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?
A. until the adolescent is afebrile
B. for 7 days following admission to the facility
C. until the adolescent has a negative blood culture
D. for 24 hrs following initiation of antimicrobial therapy
Answer: D.
Rationale:
The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr
following initiation of antimicrobial therapy. This practice will ensure that the adolescent is
no longer contagious, which protects family members and the personnel caring for the client.
Prophylactic antibiotics might be prescribed to individuals who were in close contact with the
adolescent.
29. A nurse in a health department is caring for an emancipated adolescent who has an STI
and is unaccompanied by a guardian. Which of the following actions should the nurse take?
A. have the adolescent sign a consent form for treatment
B. instruct the adolescent to return with a guardian
C. obtain consent from the adolescent's guardian over the phone
D. treat the adolescent without a consent form
Answer: A.
Rationale:
The nurse should identify that an emancipated minor can sign the consent form for treatment
of an STI or any other form of medical treatment requiring consent.
30. A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick.
Which of the following actions should the nurse take to minimize that infant's pain?
A. Use a manual lancet to obtain the heel blood sample
B. apply an ice pack to the infant's heel prior to obtaining the sample
C. allow the mother to breastfeed while the sample is being obtained
D. apply a topical lidocaine cream prior to obtaining the sample
Answer: C.
Rationale:
The nurse should allow the mother to breastfeed the infant prior to or during the procedure.
Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can
provide nonpharmacological pain management in infants.
31. A nurse is receiving change of shift report for four children. Which of the following
children should the nurse assess first?
A. a toddler who has a concussion and an episode of forceful vomiting
B. an adolescent who has infective endocarditis and reports having a headache
C. an adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of
0-10
D. a school age child who has acute glomerulonephritis and brown-colored urine
Answer: A.
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should assess this
child first. An episode of forceful vomiting is an indication of increased intracranial pressure
in a toddler who has a concussion.
32. A community health nurse is assessing an 18 month old toddler in a community day care.
Which of the following findings should a nurse identify as a potential indication of physical
neglect?
A. resists having an axillary temperature taken
B. exhibits withdrawal behaviors when their parent leaves
C. has multiple bruises on their knees
D. poor personal hygiene
Answer: D.
Rationale:
A toddler who has poor personal hygiene can be a potential indication of physical neglect.
Because toddlers are still dependent on their parents or guardians for help with hygiene
needs, poor personal hygiene can indicate a lack of supervision.
33. A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is
scheduled for surgery. Which of the following interventions should the nurse include?
A. avoid palpating the abdomen when bathing the child before surgery
B. refrain form auscultating the child's bowel sounds during the postoperative assessment
C. encourage the child to play with other children on the unit prior to surgery
D. explain to the child that their pain will be managed after the surgery
Answer: A.
Rationale:
The nurse should avoid palpating the abdomen when bathing the child before surgery because
movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and
distant to the tumor site.
34. A nurse in a provider's office is caring for a school age child who has varicella. The parent
asks the nurse when their child will no longer be contagious. Which of the following
responses should the nurse make?
A. "When your child no longer has an increased temperature."
B. "Three days after you first noticed the rash appear on your child."
C. "When you child's lesions are crusted, usually 6 days after they appear."
D. "Two to three weeks, when your child's lesions completely disappear."
Answer: C.
Rationale:
The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption
and until the vesicles have crusted over, which usually takes about 6 days.
35. A nurse is providing dietary teaching to the guardian of a school age child who has cystic
fibrosis. Which of the following statements should the nurse make?
A. "You should offer your child high protein meals and snacks throughout the day."
B. "You should decrease your child's dietary fat intake to less than 10% of their caloric
intake."
C. "You should restrict your child's calorie intake to 1200 per day."
D. "you should give your child a multivitamin once weekly."
Answer: A.
Rationale:
The nurse should instruct the guardian to provide a diet that is well-balanced and high in
protein and calories. Children who have cystic fibrosis require a higher percentage of the
recommended dietary allowances of all nutrients to meet their energy requirements. Children
who have good nutritional intake have improved lung function and decreased risk of
infection.
36. A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia.
The nurse should identify that which of the following menu items has the highest amount of
nonheme iron?
A. 1/2 cup whole milk
B. 1 cup orange juice
C. 1/2 cup raisins
D. 1 cup raw carrots
Answer: C.
Rationale:
The nurse should encourage the adolescent to eat raisins because they contain the highest
amount of nonheme iron.
37. A nurse is caring for a school age child who has primary nephrotic syndrome and is taking
prednisone. Following 1 week of treatment, which of the following manifestations indicates
to the nurse that the medication is effective?
A. decreased edema
B. increased abdominal girth
C. decreased appetite
D. increased protein in the urine
Answer: A.
Rationale:
A child who has nephrotic syndrome can experience edema due to the increased glomerular
permeability, which increases protein loss. Prednisone decreases glomerular permeability,
which causes fluid to shift from the extracellular spaces, resulting in decreased edema.
38. A nurse is providing teaching to the parents of a preschooler who has heart failure and a
new prescription for digoxin twice daily. Which of the following instructions should the nurse
include in the teaching?
A. "Use a kitchen teaspoon to measure the medication."
B. "Brush the child's teeth after giving the medication."
C. "double the next dose if the child misses a dose."
D. "repeat the dose if the child vomits."
Answer: B.
Rationale:
The nurse should instruct the parents to brush the child's teeth after administering digoxin to
prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance
the taste.
39. A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg
cast applied 24 hours ago. The nurse should instruct the guardians to report which of the
following findings to the provider?
A. capillary refill time less than 2 seconds
B. restricted ability to move the toes
C. swelling of the casted foot when the leg is dependent
D. pedal pulse +3 bilateral
Answer: B.
Rationale:
The nurse should inform the guardians that a restricted ability of the toddler to move their
toes is an indication of neurovascular compromise and requires immediate notification of the
provider. Permanent muscle and tissue damage can occur in just a few hours.
40. A nurse in an emergency department is caring for a school age child who has epiglottitis.
Which of the following actions should the nurse take?
A. obtain a throat culture form the child
B. monitor the child's oxygen saturation
C. put a warm mist humidifier in the child's room
D. place the child in the supine position
Answer: B.
Rationale:
The nurse should monitor the child's oxygen saturation level because the child is experiencing
acute respiratory distress and it is necessary to determine if the child is responding to
treatment.
41. A nurse is providing discharge teaching to the parents of a 6 month old infant who is
postoperative following hypospadias repair with a stent placement. Which of the following
instructions should the nurse include in the teaching?
A. "you may bathe your infant in an infant bathtub when you go home."
B. "apply hydrocortisone cream to your infant's penis daily."
C. "you should clamp your infant's stent twice daily."
D. "allow the stent to drain directly into your infant's diaper."
Answer: D.
Rationale:
The nurse should instruct the parents to ensure that the stent drains directly into the infant's
diaper to prevent kinking or twisting that can interfere with urine flow.
42. A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The
nurse should secure the sensor to which of the following areas on the infant?
A. wrist
B. great toe
C. index finger
D. heel
Answer: B.
Rationale:
The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting
sock on the foot to hold the sensor in place. The nurse should also check the skin under the
sensor site frequently for temperature, color, and the presence of a pulse.
43. A nurse is reviewing the laboratory results of a school age child who is 1 week
postoperative following an open fracture repair. Which of the following findings should the
nurse identify as an indication of a potential complication?
A. erythrocyte sedimentation rate 10mm/hr
B. WBC count 6200/mm3
C. c-reactive protein 1.4mg/L
D. RBC count 4.7 million/mm3
Answer: A.
Rationale:
The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the
expected reference range of up to 10 mm/hr and is an indication of osteomyelitis.
44. A nurse in an emergency department is caring for a school age child who has sustained a
minor superficial burn from fireworks on their forearm. Which of the following actions
should the nurse take?
A. administer the tetanus toxoid vaccine if more than 1 year since the prior dose
B. apply an antimicrobial ointment to the affected area
C. leave the burn area open to air
D. place an ice pack on the affected area
Answer: B.
Rationale:
The nurse should apply an antimi-crobial ointment to the burned area to prevent infection.
45. A nurse is an emergency department is assessing a toddler who has Kawasaki disease.
Which of the following findings should the nurse expect? (select all that apply.)
A. increased temperature
B. gingival hyperplasia
C. xerophthalmia
D. bradycardia
E. cervical lymphadenopathy
Answer: A, C, E.
Rationale:
Increased temperature is correct. Kawasa- ki disease is an acute illness associated with a fever
that is unresponsive to antipyretics or antibiotics. Gingival hyperplasia is incorrect. Children
who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral
mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival
hyperplasia. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease
include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Bradycardia
is incorrect. Kawasaki disease is an infection that affects the vascular system, including the
heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term
effects of Kawasaki disease include the development of coronary artery aneurysms or
myocardial infarction. Cervical lymphadenopathy is correct. A child who has Kawasaki
disease can develop enlarged cervical nodes on one side of the neck that are nontender and
greater than 1.5 cm in size.
46. A nurse is planning developmental activities for a newly admitted 10 year old child who
has neutropenia. Which of the following actions should the nurse plan to take?
A. provide the child with a book about adventure
B. arrange frequent visits from family members and peers
C. give the child a large piece puzzle
D. use puppets to entertain the child
Answer: A.
Rationale:
The nurse should provide a school-age child with a book about adventure as a developmental
activity because children are expanding their knowledge and imagination during this age.
Through reading, school-age children can feel powerful and skillful as they imagine
themselves in the stories they read.
47. A nurse is planning an educational program for school age children and their parents
about bicycle safety. Which of the following information should the nurse plan to include?
A. the child should be able to stand on the balls of their feet when sitting on the bike
B. the child should ride their bike 2 feet to the side of other bike riders
C. the child should wear dark colored clothing with a fluorescent stripe when riding at night
D. the child should ride the bike facing traffic when it is necessary to tide in the street
Answer: A.
Rationale:
To decrease the risk for injury, parents should ensure that the bike is the correct size for the
child. When seated on the bike, the child should be able to stand with the ball of each foot
touching the ground and should be able to stand with each foot flat on the ground when
straddling the bike's center bar.
48. A nurse is assessing a school age child who has an infratentorial brain tumor. Which of
the following findings should the nurse identify as a manifestation of increased intracranial
pressure?
A. hypotension
B. reports insomnia
C. difficulty concentrating
D. tachycardia
Answer: C.
Rationale:
The nurse should identify that irritability, inability to follow commands, and difficulty
concentrating are manifestations of increased intracranial pressure due to decreased blood
flow within the brain and pressure on the brainstem.
49. A nurse is teaching a group of parents about infectious mononucleosis. Which of the
following statements by a parent indicates an understanding the teaching?
A. "Mononucleosis is caused by an infection with the Epstein-Barr virus."
B. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics."
C. "A mono-spot is a throat culture used to diagnosis mononucleosis."
D. "Children who get mononucleosis will need to refrain form sports for 6 months."
Answer: A.
Rationale:
The nurse should identify that mononucleosis is a mildly contagious illness that occurs
sporadically or in groups, and is primarily caused by the Epstein-Barr virus.
50. A nurse is planning care for a newly admitted school age child who has generalized
seizure disorder. Which of the following interventions should the nurse plan to include?
A. ensure that a padded tongue blade is at the child's bedside
B. allow the child to play video games on a tablet computer
C. allow the child to take a tub bath independently
D. ensure the oxygen source is functioning in the child's room
Answer: D.
Rationale:
The nurse should recognize that maintaining the child's airway is important during a seizure.
The nurse should ensure that the oxygen source is functioning because the child might require
supplemental oxygen following a seizure.
51. A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of
Fallot and begins to have a hypercyanotic spell. Which of the following actions should the
nurse take?
A. place the infant in a knee-chest position
B. administer a dose of meperidine IV
C. discontinue administration of IV fluids
D. apply oxygen at 2L/min via nasal cannula
Answer: A.
Rationale:
The nurse should place the infant in a knee-chest position during a hypercyanotic spell to
decrease the return of desaturated venous blood from the legs and to direct more blood into
the pulmonary artery by increasing systemic vascular resistance.
52. A nurse is creating a plan of care for a child who has varicella. which of the following
interventions should the nurse include?
A. maintain the child's room temperature at 80 degrees F
B. prepare the child for a lumbar puncture
C. administer aspirin to the child for a temperature greater than 38.3 degrees C (101 degrees
F)
D. initiate airborne precautions for the child
Answer: D.
Rationale:
The nurse should initiate air borne precautions for a child who has varicella because it is
spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the
child is contagious even before lesions appear.
53. A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet
training. Which of the following instructions should the nurse include in the teaching
A. "scold your child when they have toileting accident."
B. "award your child with a sticker when they sit on the potty chair."
C. play your child's favorite song while teaching them to use the potty chair.
D. teach multiple steps of the skill at the same time.
Answer: B
Rationale:
Positive Reinforcement is Providing a reward, such as a sticker, when the child sits on the
potty chair reinforces the desired behavior and encourages repetition. Positive reinforcement
is effective in teaching new skills, especially for children with cognitive impairments, as it
provides clear and immediate feedback that the behavior is appropriate.
54. A nurse is caring for a preschooler who has congestive heart failure. The nurse observes
wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following
prescriptions should the nurse clarify with the provider?
A. furosemide
B. captopril
C. regular insulin
D. potassium chloride
Answer: D.
Rationale:
The nurse should identify that a child who has congestive heart failure can develop
electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that
the child is exhibiting manifestations of hyperkalemia and contact the provider about the
administration of potassium chloride, which can increase the severity of hyperkalemia.
55. A nurse is teaching the guardian of a 6 month old infant about teething. Which of the
following statements should the nurse make?
A. your baby might pull at their ears when they are teething.
B. "rub your baby's gums with an aspirin to decrease discomfort."
C. "place a beaded teething necklace around your baby's neck."
D. "Your baby's upper middle teeth will erupt first."
Answer: A.
Rationale:
The nurse should inform the guardian that teething can result in discomfort for the infant.
Therefore, the guardian should look for indications such as pulling on the ears, difficulty
sleeping, increased drooling, or increased fussiness.
56. A nurse is assessing a school-age child who has an acute spinal cord injury following a
sports injury 1 week ago. Identify the area the nurse should tap to elicit the bicep reflex
A. Tap on the biceps tendon in the antecubital fossa.
B. Tap on the triceps tendon just above the elbow.
C. Tap on the brachioradialis tendon at the wrist.
D. B. Tap on the triceps tendon just below the elbow.
Answer: A
Rationale:
A is correct. The nurse should identify that this is the location to tap to elicit the biceps reflex.
B is incorrect. The nurse should tap this location to elicit the triceps reflex. C is incorrect. The
nurse should tap this location to elicit the brachioradialis reflex.
57. A nurse in an emergency department is auscultating the lungs of an adolescent who is
experiencing dyspnea. The nurse should identify the sound as which of the following? (Click
on the audio button to listen to the clip).
A. Wheezes
B. Crackles.
C. Pleural friction rub
D. Rhonchi
Answer: A.
Rationale:
Wheezes. The nurse should identify the sound during auscultation as wheezes, which are
high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes
through and vibrates narrowed airways.
58. A nurse is admitting a 4-month-old infant who has heart failure. Which of the following
findings is the nurse's priority? (Click on the "Exhibit" button for additional information
about the client. There are three tabs that contain separate categories of data.)
A. Episodes of vomit
B. Formula consumption
C. Weight
D. Temperature
Answer: A.
Rationale:
Episodes of vomit When using the urgent vs. nonurgent approach to client care, the nurse
determines that the priority finding is three episodes of vomiting. This can indicate digoxin
toxicity, which requires immediate intervention; therefore, this is the priority finding.
59. A nurse is providing discharge teaching to the parent of a school age child who has
moderate persistent asthma. Which of the following instructions should the nurse include?
A. you should give your child their salmeterol inhaler every 4 hours when they are having an
acute episode of wheezing.
B. "you should monitor your child's weight weekly while they are receiving inhaled
corticosteroids therapy."
C. "pulmonary function tests will be performed every 12-24 months to evaluate how your
child is responding to therapy."
D. "when using the peak expiratory flow meter, record your child's average of three
readings."
Answer: C.
Rationale:
The nurse should inform the parent that their child will need pulmonary function tests every
12 to 24 months to evaluate the presence of lung disease and how the child is responding to
the current treatment regimen. As children grow, sometimes their manifestations can improve
or decline, and treatment needs to change accordingly.
