ATI Nursing Care of Children RN 2019 A Proctored Exam Set 3
Home Science Medicine Pediatrics
RN Nursing Care of Children Practice 2019 A ATI
1. 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.
Explanation: 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.
2. 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."
Explanation: To prevent soiling of the harness, the parent should apply the infant's diaper
under the straps. 1/60 Original
3. 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.
Explanation: 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.
4. 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."
Explanation: To prevent soiling of the harness, the parent should apply the infant's diaper
under the straps.
5. 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.
Explanation: 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.
6. 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
Explanation: The nurse should expect absence of peristalsis immediately following a
perforated appendix repair, until the bowel resumes functioning.
7. 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.
Explanation: 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.
8. 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
Explanation: 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.
9. 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."
Explanation: 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.
10. 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
Explanation: The nurse should recommend that the parent offer white rice to the child
because it is a gluten-free 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.
11. 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%
Explanation: 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,
lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying
capacity.
12. 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.
Explanation: The nurse should perform a finger stick on a toddler as a component of the
sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to
distinguish between children who have the genetic trait and children who have the disease.
13. 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
Explanation: The presence of a petechial or purpuric rash on a child who is ill can indicate
the presence of meningococcemia. This type of rash indicates the greatest risk of serious
rapid complications from sepsis and should be reported immediately to the provider.
14. 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
Explanation: 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.
15. 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.
Explanation: An infant who has an epidural hematoma is at great risk for seizure activity.
Therefore, the nurse should implement seizure precautions for the child.
16. 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
Explanation: 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.
17. A nurse in an emergency department is performing an admission assessment on a 2 weekold male newborn. Which of the following findings is the priority for the nurse to report to
the provider?
Answer: Substernal retractions
Explanation: 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.
18. 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."
Explanation: 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.
19. 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: McBurney's point is located in the right lower quadrant of the abdomen, about onethird of the distance from the anterior superior iliac spine to the umbilicus.
Explanation: 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.
20. 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
Explanation: 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 hemoglobin and hematocrit levels. The nurse should
recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to
15.5 g/dL for a 7-year-old child and should be reported to the provider.
21. 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."
Explanation: 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.
22. 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.
Explanation: The nurse should recognize that an expected developmental milestone of a 4year-old child is using scissors to cut out a shape.
23. 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.
Explanation: 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.
24. 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
Explanation: 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.
25. 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)
Explanation: 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.
26. 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.
Explanation: The nurse should suspect child maltreatment in the form of physical abuse if
the adolescent has a blunted response to painful stimuli or injury.
27. 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
Explanation: 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.
28. 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.)
-Ankle clonus
-Exaggerated stretch reflexes
-Contractures
Answer: For a toddler with spastic (pyramidal) cerebral palsy, the nurse should expect the
following findings:
Ankle clonus
Exaggerated stretch reflexes
Contractures
Explanation: Ankle clonus: This is a common sign in spastic cerebral palsy due to increased
muscle tone and hyperreflexia. It involves rapid, involuntary contractions of the ankle
muscles.
Exaggerated stretch reflexes: Spastic cerebral palsy often presents with heightened reflex
responses due to the damage in the motor pathways that control voluntary movement and
muscle tone.
Contractures: These are common in spastic cerebral palsy because the constant muscle
tightness can lead to shortened muscles and reduced joint mobility over time.
29. A nurse in a provider's office if preparing to administer immunizations to a toddler during
a well-child visit. Which of the following actions should the nurse plan to take?
Answer: Withhold the measles, mumps, and rubella (MMR) vaccine.
Explanation: 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.
30. A school nurse is assessing an adolescent who has scoliosis. Which of the following
findings should the nurse expect?
Answer: A unilateral rib hump
Explanation: 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.
31. 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."
Explanation: 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.
32. 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: The nurse should apply gentle pressure to the insertion site with a sterile gauze to
prevent bleeding and ensure proper closure of the site after removing the IV catheter.
Explanation: 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.
33. 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.
Explanation: The nurse should place the child in a side-lying position to prevent aspiration.
34. 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."
Explanation: 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.
35. 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
Explanation: 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.
36. 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.
Explanation: 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.
37. 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
Explanation: 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.
38. 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
Explanation: First, convert the child's weight from pounds to kilograms: 75 lbs ÷ 2.2 = 34
kg. Next, calculate the total daily dose: 1.2 mg/kg/day × 34 kg = 40.8 mg/day. Since each
capsule contains 40 mg, the nurse should administer 1 capsule per day (as 40 mg is closest to
the required 40.8 mg and is the practical amount available).
39. 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
Explanation: 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.
40. 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.
Explanation: The nurse should wash the affected area with mild soap and water to remove
any loose tissue that could cause infection.
41. 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
Explanation: 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.
42. 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
Explanation: The nurse should identify that an increased protein concentration in the spinal
fluid is a finding that can indicate bacterial meningitis.
43. 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
Explanation: 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.
44. 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."
Explanation: 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.
45. 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
Explanation: 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.
46. 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
Explanation: 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.
47. 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.
Explanation: 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.
48. 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
Explanation: 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.
49. A nurse is caring for a school-age child who in 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.
Explanation: 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.
50. 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.
Explanation: The nurse should schedule the toddler for a lead level rescreening in 1 year and
educate the family on ways to prevent exposure.
51. 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.
Explanation: 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.
52. 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
Explanation: Diaper dermatitis is a common inflammatory skin disorder caused by contact
with an irritant such as urine, feces, 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.
53. 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.
Explanation: 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.
54. 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
Explanation: 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.
55. 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."
Explanation: The child should administer regular insulin 30 min before meals so that the
onset coincides with food intake.
56. 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."
Explanation: The nurse should inform the parent that protective factors against SIDS include
breastfeeding and the use of a pacifier when the infant is sleeping.
57. The nurse is assessing a school-age child who has peritonitis. Which of the following
findings should the nurse expect?
Answer: Abdominal distension
Explanation: 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.
58. 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.
Explanation: 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.
59. 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."
Explanation: The nurse should instruct the parent to shake the medication prior to
administration to disperse the medication evenly within the suspension.
60. 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.
Explanation: The nurse should initiate droplet precautions for a child who has pertussis, also
known as whooping cough. Pertussis is transmitted through contact with infected largedroplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.
61. 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 Your vote matters in the 2020 presidential election.
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Explanation: For a toddler with acute diarrhea and moderate dehydration, the nurse should
offer oral rehydration solutions (ORS). ORS are specifically designed to replace lost fluids
and electrolytes effectively, helping to prevent further dehydration and support recovery.
Avoid giving fruit juices or soft drinks, as they can worsen diarrhea.
62. 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.
Explanation: 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.
63. 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."
Explanation: To prevent soiling of the harness, the parent should apply the infant's diaper
under the straps.
64. 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.
Explanation: 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.
65.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."
Explanation: To prevent soiling of the harness, the parent should apply the infant's diaper
under the straps.
66. 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.
Explanation: 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.
66. 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
Explanation: The nurse should expect absence of peristalsis immediately following a
perforated appendix repair, until the bowel resumes functioning.
67. 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.
Explanation: 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.
68. 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
Explanation: 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.
69. 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."
Explanation: 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.
70. 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
Explanation: The nurse should recommend that the parent offer white rice to the child
because it is a gluten-free 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.
71. 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%
Explanation: 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,
lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying
capacity.
72. 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.
Explanation: The nurse should perform a finger stick on a toddler as a component of the
sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to
distinguish between children who have the genetic trait and children who have the disease.
73. 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
Explanation: The presence of a petechial or purpuric rash on a child who is ill can indicate
the presence of meningococcemia. This type of rash indicates the greatest risk of serious
rapid complications from sepsis and should be reported immediately to the provider.
74. 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
Explanation: 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.
75. 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.
Explanation: An infant who has an epidural hematoma is at great risk for seizure activity.
Therefore, the nurse should implement seizure precautions for the child.
76. 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
Explanation: 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.
77. A nurse in an emergency department is performing an admission assessment on a 2 weekold male newborn. Which of the following findings is the priority for the nurse to report to
the provider?
Answer: Substernal retractions
Explanation: 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.
78. 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."
Explanation: 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.
79. 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: McBurney's point is located in the right lower quadrant of the abdomen,
approximately one-third of the distance from the anterior superior iliac spine to the umbilicus.
Explanation: 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.
80. 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
Explanation: 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 hemoglobin and hematocrit levels. The nurse should
recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to
15.5 g/dL for a 7-year-old child and should be reported to the provider.
81. 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."
Explanation: 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.
82. 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.
Explanation: The nurse should recognize that an expected developmental milestone of a 4year-old child is using scissors to cut out a shape.
83. 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.
Explanation: 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.
84. 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
Explanation: 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.
85. 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)
Explanation: 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.
86. 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.
Explanation: The nurse should suspect child maltreatment in the form of physical abuse if
the adolescent has a blunted response to painful stimuli or injury.
87. 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
Explanation: A child who has a head injury can develop SIADH as a result of altered
pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion 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.
88. 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.)
-Ankle clonus
-Exaggerated stretch reflexes
-Contractures
Answer: For a toddler with spastic (pyramidal) cerebral palsy, the nurse should expect the
following findings:
Ankle clonus
Exaggerated stretch reflexes
Contractures
Explanation: Ankle clonus: This is a common sign in spastic cerebral palsy due to increased
muscle tone and hyperreflexia. It involves rapid, involuntary contractions of the ankle
muscles.
Exaggerated stretch reflexes: Spastic cerebral palsy often presents with heightened reflex
responses due to the damage in the motor pathways that control voluntary movement and
muscle tone.
Contractures: These are common in spastic cerebral palsy because the constant muscle
tightness can lead to shortened muscles and reduced joint mobility over time.
89. A nurse in a provider's office if preparing to administer immunizations to a toddler during
a well-child visit. Which of the following actions should the nurse plan to take?
Answer: Withhold the measles, mumps, and rubella (MMR) vaccine.
Explanation: 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.
90. A school nurse is assessing an adolescent who has scoliosis. Which of the following
findings should the nurse expect?
Answer: A unilateral rib hump
Explanation: 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.
91. 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."
Explanation: 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.
92. 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: The nurse should apply gentle pressure to the insertion site with a sterile gauze to
prevent bleeding and ensure proper closure of the site after removing the IV catheter.
Explanation: 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.
93. 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.
Explanation: The nurse should place the child in a side-lying position to prevent aspiration.
94. 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."
Explanation: 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.
95. 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
Explanation: 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.
96. 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.
Explanation: 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.
97. 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
Explanation: 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.
98. 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
Explanation: First, convert the child's weight from pounds to kilograms: 75 lbs ÷ 2.2 = 34
kg. Calculate the total daily dose: 1.2 mg/kg/day × 34 kg = 40.8 mg/day. Since each capsule
contains 40 mg, the nurse should administer 1 capsule per day to closely match the prescribed
dose, as 40 mg is the nearest practical amount available.
99. 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
Explanation: 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.
100. 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.
Explanation: The nurse should wash the affected area with mild soap and water to remove
any loose tissue that could cause infection.
101. 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
Explanation: 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.
102. 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
Explanation: The nurse should identify that an increased protein concentration in the spinal
fluid is a finding that can indicate bacterial meningitis.
103. 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
Explanation: 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.
104. 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."
Explanation: 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.
105. 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
Explanation: 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.
106. 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
Explanation: 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.
107. 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.
Explanation: 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.
108. 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
Explanation: 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.
109. A nurse is caring for a school-age child who in 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.
Explanation: 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.
110. 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.
Explanation: The nurse should schedule the toddler for a lead level rescreening in 1 year and
educate the family on ways to prevent exposure.
111. 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.
Explanation: 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.
112. 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
Explanation: Diaper dermatitis is a common inflammatory skin disorder caused by contact
with an irritant such as urine, feces, 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.
113. 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.
Explanation: 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.
114. 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
Explanation: 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.
115. 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."
Explanation: The child should administer regular insulin 30 min before meals so that the
onset coincides with food intake.
116. 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."
Explanation: The nurse should inform the parent that protective factors against SIDS include
breastfeeding and the use of a pacifier when the infant is sleeping.
117. The nurse is assessing a school-age child who has peritonitis. Which of the following
findings should the nurse expect?
Answer: Abdominal distension
Explanation: 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.
118. 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.
Explanation: 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.
119. 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."
Explanation: The nurse should instruct the parent to shake the medication prior to
administration to disperse the medication evenly within the suspension.
120. 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.
Explanation: The nurse should initiate droplet precautions for a child who has pertussis, also
known as whooping cough. Pertussis is transmitted through contact with infected largedroplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.
121. 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
Explanation: 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.
122. 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.
Explanation: 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 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.
123. 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.
Explanation: 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.
