Preview Extract
ATI RN Nursing Care of Children
Practice 2019 A and B Graded A /2023-2024
A nurse is creating a plan of care for a school-age child who has heart disease and has developed
heart failure. Which of the following interventions should the nurse include in the plan?
Answer: Provide small, frequent meals for the child.
Rationale:
The metabolic rate of a child who has heart failure is high because of poor cardiac function.
Therefore, the nurse should provide small, frequent meals for the child because it helps to
conserve energy.
A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of
developmental dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
Answer: "I will place my infant's diapers under the harness straps."
Rationale:
To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury
(AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the
nurse include in the plan?
Answer: Initiate seizure precautions for the child.
Rationale:
A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for
neurological deficits and seizure activity. The nurse should complete a neurologic assessment
and implement seizure precautions to maintain the child's safety.
A nurse is assessing a school-age child immediately following a perforated appendix repair.
Which of the following findings should the nurse expect?
Answer: Absence of peristalsis
Rationale:
The nurse should expect absence of peristalsis immediately following a perforated appendix
repair, until the bowel resumes functioning.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should
the nurse take?
Answer: Apply topical analgesic cream to the site 1 hr prior to the procedure.
Rationale:
The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to
decrease the adolescent's pain while the lumbar needle is inserted.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The
child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the
medication infusion, which of the following medications should the nurse administer first?
Answer: Epinephrine
Rationale:
This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to
evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis.
Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of
blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: "I should keep my child indoors when I mow the yard."
Rationale:
The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or
when the pollen count is increased. Guarding against exposure to known allergens found
outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's
asthma attacks.
A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease.
The nurse should recommend that the parent offer which of the following foods to the child?
Answer: White rice
Rationale:
The nurse should recommend that the parent offer white rice to the child because it is a glutenfree food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free
diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose
deficiency can be secondary to this disease.
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue.
Which of the following findings should the nurse recognize as an indication of anemia?
Answer: Hematocrit 28%
Rationale:
The nurse should recognize that this hematocrit level is below the expected reference range of
32% to 44% for a school-age child. The child can exhibit fatigue, light headedness, tachycardia,
dyspnea, and pallor due to the decreased oxygen carrying capacity.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the
following actions should the nurse plan to take?
Answer: Perform a finger stick.
Rationale:
The nurse should perform a finger stick on a toddler as a component of the sickle turbidity test. If
the test is positive, haemoglobin electrophoresis is required to distinguish between children who
have the genetic trait and children who have the disease.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is
the priority for the nurse to report to the provider?
Answer: Petechiae on the lower extremities
Rationale:
The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of
meningococcaemia. This type of rash indicates the greatest risk of serious rapid complications
from sepsis and should be reported immediately to the provider.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following
findings should the nurse expect?
Answer: Loud, harsh murmur
Rationale:
The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the
left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury.
Which of the following interventions should the nurse include in the plan?
Answer: Implement seizure precautions for the infant.
Rationale:
An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse
should implement seizure precautions for the child.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following
findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Answer: Serum creatinine 3.0 mg/dL
Rationale:
Creatinine is a byproduct of protein metabolism and is excreted from the body through the
kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are
not functioning. The nurse should identify that the adolescent's serum creatinine level is higher
than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate
rejection of the kidney.
A nurse in an emergency department is performing an admission assessment on a 2 week-old
male newborn. Which of the following findings is the priority for the nurse to report to the
provider?
Answer: Substernal retractions
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 substernal retractions. This finding
indicates the newborn is experiencing increased respiratory effort, which could quickly progress
to respiratory failure.
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse
that he cannot cope anymore and has decided to move out of the house. Which of the following
statements should the nurse make?
Answer: "Let's talk about some of the ways you have handled previous stressors in your life."
Rationale:
This statement offers a general lead to allow the parent to express their feelings and previous
actions when faced with stressful situations. It also helps the parent to focus on ways that they
can cope with the current situation.
A nurse in an emergency department is caring for an adolescent who has severe abdominal pain
due to appendicitis. Which of the following locations should the nurse identify as McBurney's
point?
Answer: A. The nurse should identify this area of the client's abdomen as McBurney's point.
This area of the right lower quadrant located about two-thirds of the way between the umbilicus
and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most
likely to report pain and tenderness.
Rationale:
McBurney's point, located about two-thirds of the way between the umbilicus and the
anterosuperior iliac spine, is a critical area for diagnosing appendicitis due to tenderness and
pain. Its significance lies in its proximity to the appendix's location, aiding in accurate diagnosis
and prompt intervention. Identifying pain at this point can help confirm the suspicion of
appendicitis and guide further assessment and treatment.
A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy.
Which of the following lab values should the nurse report to the provider?
Answer: Hgb 8.5 g/dL
Rationale:
A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the
blood-forming cells of the bone marrow. The development of anemia is diagnosed through
laboratory testing of haemoglobin and hematocrit levels. The nurse should recognize that a
haemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7year-old child and should be reported to the provider.
A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical
procedure. The client asks, "who should sign my surgical consent?" Which of the following
responses should the nurse make?
Answer: "You can sign the consent form because you are married."
Rationale:
The nurse should inform the adolescent that marriage gives adolescents the legal right to consent
to surgical procedures and sign other legal documents that they would not otherwise be able to
sign due to their age.
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following
developmental milestones should the nurse expect to observe?
Answer: Cuts an outlined shape using scissors.
Rationale:
The nurse should recognize that an expected developmental milestone of a 4year-old child is
using scissors to cut out a shape.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following
actions should the nurse implement for infection control?
Answer: Have a designated stethoscope in the infant's room.
Rationale:
The nurse should initiate droplet precautions for an infant who has RSV because the virus is
spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a
blood pressure cuff and a stethoscope, should be placed in the infant's room.
A nurse in an emergency department is caring for a school-age child who has appendicitis and
rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the
nurse take?
Answer: Give morphine
0.05mg/kg IV
Rationale:
A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an
analgesic medication for pain relief.
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse
should identify that which of the following findings in an indication of early septic shock?
Answer: Temperature 39.1°C (102.4°F)
Rationale:
The nurse should identify that a temperature of 39.1°C (102.4°F) is above the expected reference
range of 37°to 37.5°C (98.6°to 99.5°F) for a 10-year-old child. The nurse should expect a child
who has early septic shock to have a fever and chills.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing.
Which of the following behaviors should the nurse identify as a possible indication of physical
abuse?
Answer: Denies discomfort during assessment of injuries.
Rationale:
The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a
blunted response to painful stimuli or injury.
A nurse is caring for a 15 year-old client following a head injury. Which of the following
findings should the nurse identify as an indication that the child is developing syndrome of
inappropriate antidiuretic hormone secretion (SIADH)?
Answer: Mental confusion
Rationale:
A child who has a head injury can develop SIADH as a result of altered pituitary function,
leading to an over-secretion of antidiuretic hormone. Over-secretion of antidiuretic hormone
leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As
the hyponatremia becomes more severe, mental confusion and other neurologic manifestations
such as seizures can occur.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the
following findings should the nurse expect? (Select all that apply.)
Answer: • Ankle clonus
• Exaggerated stretch reflexes
• Contractures
Rationale:
In spastic (pyramidal) cerebral palsy, the nurse can expect to find ankle clonus, characterized by
rhythmic muscle contractions and relaxations, and exaggerated stretch reflexes due to increased
muscle tone and spasticity. Additionally, contractures, or permanent shortening of muscles,
commonly occur, leading to joint stiffness and limited range of motion. These findings reflect the
characteristic motor impairments associated with spastic cerebral palsy.
A nurse in a provider's office if preparing to administer immunizations to a toddler during a wellchild visit. Which of the following actions should the nurse plan to take?
Answer: Withhold the measles, mumps, and rubella (MMR) vaccine.
Rationale:
The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a
contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or
gelatin should not receive this vaccine.
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings
should the nurse expect?
Answer: A unilateral rib hump
Rationale:
When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib
hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine
resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a
neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is caring for a preschooler whose father is going home for a few hours while another
relative stays with the child. Which of the following statements should the nurse make to explain
to the child when their father will return?
Answer: "Your daddy will be back after you eat."
Rationale:
Preschoolers make sense of time best when they can associate it with an expected daily routine,
such as meals and bedtime. Therefore, the child comprehends time best when it is explained to
them in relation to an event they are familiar with, such as eating.
The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV
catheter. When preparing to discontinue the IV fluids and catheter, which of the following
actions should the nurse plan to take?
Answer: First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV
tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over
the catheter insertion site.
Rationale:
When discontinuing IV fluids and catheter, the nurse should first turn off the IV pump to stop the
infusion, then occlude the IV tubing to prevent air from entering, followed by removing the tape
securing the catheter and applying pressure over the insertion site to minimize bleeding and
promote hemostasis.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the
following actions should the nurse take during the immediate postictal period?
Answer: Place the child in a side-lying position.
Rationale:
The nurse should place the child in a side-lying position to prevent aspiration.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the
following statements by the guardian indicates an understanding of the teaching?
Answer: "I should secure the car seat using lower anchors and tethers instead of the seat belt."
Rationale:
Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an
infant's car seat in the vehicle. This system provides anchors between the front cushion and the
back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be
used.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract
infection. Which of the following findings should the nurse identify as a manifestation of
pertussis?
Answer: Dry, hacking cough
Rationale:
The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease
usually begins with indications of an upper respiratory tract infection, which includes a dry,
hacking cough that is sometimes more severe at night.
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following
actions should the nurse plan to take?
Answer: Administer the immunization using a 24-gauge needle.
Rationale:
The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge
needle to minimize the amount of pain the child experiences.
The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative
following a cleft palate repair. For which of the following members of the inter professional team
should the nurse initiate a referral?
Answer: Speech therapist
Rationale:
The nurse should initiate a referral for a speech therapist for a child who is postoperative
following a cleft palate repair. A child who has a cleft palate will require speech therapy
immediately following the repair to support speech development and future articulation.
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child
who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the
nurse administer per day?
Answer: 1 capsule
Rationale:
For a school-aged child weighing 75 lbs, the dose of atomoxetine is calculated as 1.2 mg/kg/day.
Converting the weight to kilograms (75 lbs ÷ 2.2 = 34.09 kg), the total daily dose would be
approximately 41 mg (1.2 mg/kg/day * 34.09 kg). Since the available atomoxetine capsules are
40 mg each, the nurse would administer 1 capsule per day to achieve the prescribed dose.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the
following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Answer: Flank pain
Rationale:
The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an
indication of a hemolytic reaction to the blood transfusion.
A nurse in the emergency department is caring for a toddler who has a partial thickness burns on
their right arm. Which of the following actions should the nurse take?
Answer: Cleanse the affected area with mild soap and water.
Rationale:
The nurse should wash the affected area with mild soap and water to remove any loose tissue that
could cause infection.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the
sound as which of the following?
Answer: Tachypnea
Rationale:
The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid,
regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic
acidosis, or severe anemia.
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having
bacterial meningitis. Which of the following results should the nurse identify as a finding
associated with bacterial meningitis?
Answer: Increased protein concentration
Rationale:
The nurse should identify that an increased protein concentration in the spinal fluid is a finding
that can indicate bacterial meningitis.
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following
manifestations should the nurse report to the provider?
Answer: Respiratory rate 45/min
Rationale:
The nurse should identify that a respiratory rate of 45/min is above the expected reference range
of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute
respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of
the tibia. The nurse should identify that which of the following statements by the parents
indicates an understanding of the teaching?
Answer: "My child will receive antibiotics for several weeks."
Rationale:
The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4
weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is providing teaching about social development to the parents of a preschooler. Which of
the following play activities should the nurse recommend for the child?
Answer: Playing dress-up
Rationale:
The nurse should instruct the parents that at the preschool age, play should focus on social,
mental, and physical development. Therefore, playing dress-up is a recommended play activity
for this child.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe
dehydration. The nurse should identify that which of the following laboratory values indicates
effectiveness of the current treatment?
Answer: Sodium 140 mEq/L
Rationale:
The nurse should identify that a sodium level of 140 mEq/L is within the expected reference
range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for
dehydration is effective.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound
debridement following a burn injury. Which of the following actions should the nurse take prior
to the procedure?
Answer: Administer an analgesic to the child.
Rationale:
Hydrotherapy for debridement of a wound is an extremely painful procedure which requires
analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on
the body caused by stress and decreases the likelihood of children developing depression and
post-traumatic stress disorder.
A charge nurse in an emergency department is preparing an in-service for a group of newly
licensed nurses on the clinical manifestations of child maltreatment. Which of the following
manifestations should the charge nurse include as suggestive of potential physical abuse?
Answer: Symmetric burns of the lower extremities
Rationale:
The nurse should include that symmetric burns to the lower extremities can indicate physical
abuse. The patterns are usually characteristic of the method or object used, such as cigar or
cigarette burns, or burns in the shape of an iron.
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr
ago. Which of the following actions should the nurse take?
Answer: Assess peripheral pulses once every 4 hr.
Rationale:
Buck's traction is a type of skin traction that can be used to immobilize extremities prior to
surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first
24 hr of placement in Buck's traction. The nurse should monitor and report signs of
neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and
tingling.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the
following actions should the nurse plan to take?
Answer: Schedule the toddler for a yearly rescreening.
Rationale:
The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the
family on ways to prevent exposure.
A nurse is receiving change-of-shift report on four children. Which of the following children
should the nurse see first?
Answer: A school-age child who has sickle cell anemia and reports decreased vision in the left
eye.
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine the
priority finding is a report of decreased vision in the left eye. This finding indicates that the child
is experiencing a vaso-occlusive crisis and should be reported to the provider immediately.
Therefore, the nurse should see this child first.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse
should instruct the parent to apply which of the following to the affected area?
Answer: Zinc oxide
Rationale:
Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant
such as urine, faces, soap, or friction, and takes the form of scaling, blisters, or papules with
erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin
to heal.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely
immunocompromised. Which of the following actions should the nurse take?
Answer: Screen the child's visitors for indications of infection.
Rationale:
A child who is severely immunocompromised is unable to adequately respond to infectious
organisms, resulting in the potential for overwhelming infection.
Therefore, the nurse should screen the child's visitors for indications of infection.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of
dehydration. Which of the following findings is the nurses priority?
Answer: Tachypnea
Rationale:
When using the airway, breathing, and circulation approach to client care, the nurse's priority
finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete
hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus.
Which of the following statements by the child indicates an understanding of the teaching?
Answer: "I will give myself a shot of regular insulin 30 minutes before I eat breakfast."
Rationale:
The child should administer regular insulin 30 min before meals so that the onset coincides with
food intake.
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome
(SIDS). Which of the following instructions should the nurse include?
Answer: "Give the infant a pacifier at bedtime."
Rationale:
The nurse should inform the parent that protective factors against SIDS include breastfeeding
and the use of a pacifier when the infant is sleeping.
The nurse is assessing a school-age child who has peritonitis. Which of the following findings
should the nurse expect?
Answer: Abdominal distension
Rationale:
The nurse should identify that abdominal distention is an expected finding of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the
abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations
include chills, irritability, and restlessness.
The nurse is interviewing the parent of an 18-month-old toddler during a well child visit. The
nurse should identify that which of the following findings indicates a need to assess the toddler
for hearing loss?
Answer: The toddler received tobramycin during a hospitalization 2 weeks ago.
Rationale:
The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that
can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse is providing teaching to the parent of a school-age child who has a new prescription for
oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the
nurse include?
Answer: "Shake the medication prior to administration."
Rationale:
The nurse should instruct the parent to shake the medication prior to administration to disperse
the medication evenly within the suspension.
A nurse is admitting a school-age child who has Pertussis. Which of the following actions should
the nurse take?
Answer: Initiate droplet precautions for the child.
Rationale:
The nurse should initiate droplet precautions for a child who has pertussis, also known as
whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that
are suspended in the air when the child coughs, sneezes, or talks.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration.
Which of the following nutritional items should the nurse offer to the toddler?
Answer: Oral rehydration solution
Rationale:
A toddler who has acute diarrhea should consume an oral rehydration solution to replace
electrolytes and water by promoting the reabsorption of water and sodium. This promotes
recovery from dehydration.
A nurse in an emergency department is caring for a school-age child who is experiencing an
anaphylactic reaction. Which of the following is the priority action by the nurse?
Answer: Administer epinephrine IM to the child.
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the
priority action is administering epinephrine IM to the child. During an anaphylactic reaction,
histamine release causes bronchoconstriction and vasodilation. This is an emergency because
ultimately this causes decreased blood return to the heart.
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 insipidus?
Answer: Sodium 155 mEq/L
Rationale:
A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction
leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to
polyuria and polydipsia, and possibly dehydration. When the excessive loss of free water, sodium
levels rise above the expected reference range of 136-145 mEq/L
A nurse is creating a plan of care for a child who has varicella. Which of the following
interventions should the nurse include?
Answer: Initiate airborne precautions for the child
Rationale:
The nurse should initiate airborne 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
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?
Answer: "I will notify the doctor if I notice that my child is swallowing frequently."
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.
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot
and begins to have a hyper cyanotic spell. Which of the following actions should the nurse take?
Answer: Place the infant to a knee-chest position
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
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?
Answer: Palpate the dorsum of the child's feet
Rationale:
The nurse should palpate the dorsum of the feet by pressing the fingertip against a body
prominence for 5 seconds to assess for peripheral edema
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?
Answer: Potassium chloride
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
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?
Answer: The child should be able to stand on the balls of their feet when sitting on the bike.
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.
A nurse is providing discharging teaching to the parent of an 18-month-old toddler who
dehydration due to acute diarrhea. Which of the following statements by the parent indicates an
understanding of the teaching?
Answer: "I will monitor my child's number of wet diapers."
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.
A nurse is providing anticipatory guidance to the mother of a toddler. Which of the following
expected behavior characteristics of toddlers should the nurse include in the teaching?
Answer: Expresses likes and dislikes
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.
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?
Answer: Erythrocyte sedimentation rate 18mm/hr
Rationale:
The nurse should identify that an erythrocyte sedimentation rate of 18mm/hr is above the
expected reference range of up to 10mm/hr and is an indication of osteomyelitis.
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?
Answer: Use a semipermeable transparent dressing to cover the site
Rationale:
The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of
infection.
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?
Answer: Increase fat content in the child's diet to 40% of total calories
Rationale:
In cystic fibrosis, increasing the fat content in the child's diet to 40% of total calories is essential
to meet increased energy demands and aid in the absorption of fat-soluble vitamins,
compensating for malabsorption due to pancreatic insufficiency. Fat provides a concentrated
source of calories, supporting optimal growth and development in children with cystic fibrosis
and helping to maintain a healthy weight. This intervention aligns with nutritional
recommendations to optimize nutrition and minimize nutritional deficiencies in cystic fibrosis
management.
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
35-40-% of total caloric intake Wheezes
Answer: High pitched, musical or whistling-like sound heard primarily on expiration as air
passes through and vibrates narrowed airways
Rationale:
High-pitched wheezes, which are musical or whistling-like sounds heard primarily on expiration,
occur due to narrowed airways in cystic fibrosis, reflecting airway obstruction and increased
resistance to airflow. These wheezes result from mucus accumulation, inflammation, and
bronchoconstriction, highlighting the need for airway clearance interventions and bronchodilator
therapy to alleviate symptoms and improve respiratory function in children with cystic fibrosis.
Recognizing and addressing wheezes promptly can prevent respiratory complications and
optimize lung health in cystic fibrosis management.
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?
Answer: Difficulty concentrating
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.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the
priority for the nurse to report to the provider?
Answer: Nasal flaring
Rationale:
When using the airway, breathing, and circulation approach to clients 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
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?
Answer: Have the adolescent sign a consent form for treatment of an STI or any other form of
medical treatment requiring consent
Rationale:
The nurse should have the emancipated adolescent sign a consent form for treatment of their STI
or any other medical treatment requiring consent, as they have the legal authority to provide
informed consent for their own healthcare.
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?
Answer: "I should wear sandals as much as possible."
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 that adolescent that wearing
sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infections
A nurse is assessing an 8-year-old child who has early indication of shock. After establishing an
airway and stabilizing the child's respiration, which of the following actions should the nurse
take next?
Answer: Initiate IV access
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
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?
Answer: Disease process
Rationale:
The transmission of infectious diseases is the greatest risk to the child and other children on the
unit. Therefore, the child's disease process is the nurse's priority consideration
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?
Answer: Sunken anterior fontanel
Rationale:
The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe
hydration due to the acute loss of fluid
A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above
38.0º C (100.5º F) to an infant who weighs 17.6 lbs. Available is ibuprofen oral suspension
100mg/5mL. How many mL should the nurse administer to the infant per dose? (Round the
answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Answer: 2 mL
Rationale:
(5ml/100mg) × (5mg/ 1 kg) × (1 kg/2.2 lbs) × (17.6 lbs/1) = 440/220 = 2
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?
Answer: "You should offer your child high-protein meals and snacks throughout the day."
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 allowance of all nutrients to meet their energy requirements. Children who have a good
nutritional intake have improved lung function and decreased risk of infection.
A nurse is reviewing the dietary choice 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?
Answer: 1/2 cup raisins
Rationale:
The nurse should encourage the adolescent to eat raisins because they contain the highest amount
of nonheme iron
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is
postoperative following hypospadias repair with a sent placement. Which of the following
instructions should the nurse include in the teaching?
Answer: "Allow the stent to drain directly into your infant's diaper."
Rationale:
The nurse should instruct the parents to ensure that the sent drains directly into the infant's diaper
to prevent kinking or twisting that can interfere with urine flow
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?
Answer: Monitor the child's oxygen saturation
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
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?
Answer: "when your child's lesions are crusted, usually 6 days after they appear."
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.
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic
arthritis. Which of the following instructions should the nurse include in the teaching?
Answer: "Encourage the child to perform independent self-care."
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 self-esteem
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?
Answer: "I will teach challenging academic subjects to the students who have ADHD in the
morning."
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
A nurse is planning and educational program to teach parents about protecting their children
from sunburns. Which of the following instructions should the nurse plan to include?
Answer: "Choose a waterproof sunscreen with a minimum SPF of 15."
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
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?
Answer: Ensure the oxygen source is functioning in the child's room
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
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?
Answer: Recombinant growth hormone
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 prescriber this
treatment.
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?
Answer: Avoid palpating the abdomen when bathing the child before surgery
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
A nurse is discussing organ donation with the parents of a school-age child who has sustain brain
death due to a bicycle crash. Which of the following actions should the nurse take first?
Answer: Explore the parents' feeling and wishes regarding organ donation
Rationale:
The nurse should first explore the parents' feelings and wishes regarding organ donation,
respecting their emotional state and providing support during this difficult time while also
addressing the potential for organ donation.
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 biceps reflex.
Answer: The first one in the image (to the left) The nurse should identify that this is the location
to tap to elicit the biceps reflex
Rationale:
The nurse should tap the area corresponding to the biceps tendon, which is located just above the
antecubital fossa on the inner aspect of the elbow, to elicit the biceps reflex, assessing upper
motor neuron function in the child with a spinal cord injury.
A nurse is planning development activities for a newly admitted 10-year-old child who has a
neutropenia. Which of the following actions should the nurse plan to take?
Answer: Provide the child with a book about adventure.
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 skill full as they imagine themselves
in their stories they read
A community health nurse is assessing an 18-month-old toddler in a community day care. Which
of the following findings should the nurse identify as a potential identification of psychical
neglect?
Answer: Poor personal hygiene
Rationale:
A toddler who has poor personal hygiene can be a potential indication of a 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
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings
is the nurse's priority?
Answer: Episodes of vomiting
Rationale:
When using the urgent vs. nonurgent approach to the client care, the nurse should determine that
the priority finding is thee episodes of vomiting. This can indicate digoxin toxicity, which
requires immediate intervention. Therefore, this is the nurse's priority finding.
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 instruction should the nurse include
in the teaching?
Answer: "Brushing the child's teeth after giving the medication."
Rationale:
The nurse should instruct the parents to brush the child's teeth after administering digoxin to
prevent tooth decay caused by the medications, which comes as a sweetened liquid to enhance
the taste.
A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain
assessment scales should the nurse use?
Answer: FACES
Rationale:
The nurse should use the FACES pain rating scale for paediatric 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 paint management.
A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following
statements should the nurse make?
Answer: "Your baby might pull at their ears when they are teething."
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 a pulling on the ears, difficulty
sleeping, increased drooling, or increased fussiness
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?
Answer: An 8-month-old infant who is not yet making babbling sounds
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.
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?
Answer: "Award your child with a sticker when they sit on the potty chair."
Rationale:
A child who has a cognitive impairment learns through shaping behaviors. The parents should
reward the child for sitting on the potty chair as a reinforcement of a desired behavior of
continence. As the child repeats this action, the parents can gradually decrease this reward and
then give rewards for the next step in the task, such as voiding while sitting on the potty chair
A nurse is teaching a school-age child and their parents about postoperative care following
cardiac catheterization. Which of the following instruction should the nurse include?
Answer: "Wait 3 days before taking a tub bath."
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.
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?
Answer: Decreased edema
Rationale:
A child who has nephrotic syndrome can experience edema due to the increase glomerular
permeability, which increased protein loss. Prednisone decreases glomerular permeability, which
causes fluid shift from the extracellular spaces, resulting in decreased edema
A nurse is receiving change-of-shift report for four children. Which of the following children
should the nurse assess first?
Answer: A toddler who has a concussion and an episode of forceful vomiting
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 is a
toddler who has a concussion
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following
statements by a parent indicates an understanding of the teaching?
Answer: "Mononucleosis is caused by an infection with the Epstein Barr virus."
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
A nurse is an emergency department is caring for a school-age child who sustained a minor
superficial burn from fireworks on their forearm. Which of the following actions should the
nurse take?
Answer: Apply an antimicrobial ointment to the affected area
Rationale:
The nurse should apply an antimicrobial ointment to the nursed area to prevent infection
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following
actions should the nurse take first?
Answer: Check the child's respiratory rate
Rationale:
When using the airway, breathing, and circulation approach to the client care, the nurse should
determine the priority action is the assess the child's respiratory rate. If the child is not breathing,
the nurse should admitter rescue breaths.
A nurse is caring for a 1-month-old infant who is breastfeeding and required a heel stick. Which
of the following actions should the nurse take the minimize the infant's pain?
Answer: Allow the mother to breastfeed while the sample is being obtained
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
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?
Answer: For 24 hr following initiation of antimicrobial therapy
Rationale:
The nurse should plan to maintain the adolescent on droplet precautions for a least 24 hour
following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no
longer contagious, which protect family members and the personnel caring for the client.
Prophylactic antibiotics might be prescribed to individuals who were in close contact with the
adolescent.
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 area on the infant?
Answer: Great toe
Rationale:
A nurse is monitoring the oxygen saturation level of an 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.
A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast
applied 24 hr ago. The nurse should instruct the guardians to report which of the following
findings to the provider?
Answer: Restricted ability to move the toes
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
A nurse is caring for a school-age 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?
Answer: Deep respirations of 32/min
Rationale:
The nurse should expect Kussmaul respiration 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.
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?
Answer: "Pulmonary function tests will be performed every 12 to 24 months to evaluate how
your child is responding to therapy"
Rationale:
The nurse should inform the parent that their child will need pulmonary function tests every 1224 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
A nurse is caring for a toddler who has acute otitis media and a temperature of 40ºC (104º F).
After administering acetaminophen, which of the following actions should the nurse plan to take
to reduce the toddler's temperature?
Answer: Dress the toddler in minimal clothing
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
A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of
the following findings should the nurse expect?
Answer: Increased temperature - Kawasaki disease is an acute illness associated with a fever
that is unresponsive to antipyretics or antibiotics
Rationale:
Xerophthalmia - ophthalmic manifestations of Kawasaki disease include reddening of the
conjunctive and dryness of the eyes, or xerophthalmia. Cervical lymphadenopathy- 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
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?
Answer: Presence of strabismus
Rationale:
Strabismus, or cross 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.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which
of the following findings indicates effectiveness of the medication?
Answer: Serum potassium level 4.1 mEq/L
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 4.6 mEq/L indicates the effectiveness of the medication
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?
Answer: "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3
days."
Rationale:
The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's
suture line daily the 3 days and then continue to apply petroleum jelly to the area for several
weeks to promote healing
A nurse is admitting an infant who has intussusception. Which of the following findings should
the nurse expect? (Select all that apply)
Answer: Vomiting - 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
Rationale:
Lethargy - 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
