Preview Extract
2023-2024/PEDS ATI PROCTORED FINAL EXAM TEST
BANK 60 QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES|AGRADE
1. The nurse is preparing to administer an immunization to a four-year-old child.
Which of the following actions should the nurse plan to take?
A. Place the child in a prone position for the immunization
B. request that the child's caregiver leave the room during the immunization
C. administer the immunization using a 24-gauge needle
D. inject the immunization slowly after aspirating for 3 seconds
Answer: c
Rationale:
The nurse should administer an immunization for a 4-year-old child using a 24- gauge needle to
minimize the amount of pain experienced by the toddler.
A. The nurse should place the child in an upright sitting position for the immunization because
this decreases the child's fear and anxiety.
B. The nurse should allow the caregiver to stay near the child during the immunization to provide
a sense of security and reduce the child's anxiety level.
D. The nurse should inject the immunization rapidly and avoid aspiration.
These actions decrease the risk of needle displacement and lower the child's fear and anxiety
level by decreasing the amount of time it takes to administer the immunization.
2. A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe
dehydration. The nurse should identify which of the following laboratory values indicates
effectiveness of the current treatment?
A. Potassium 2.9 mEq/L
B. sodium 140
C. urine specific gravity 1.035
D. BUN 25 mg
Answer: b
Rationale:
The nurse should identify that a sodium level of 140 mEq/L is within the expected reference
range and indicates the current treatment regimen the infant is receiving for dehydration is
effective.
A. A potassium level of 2.9 mEq/L is below the expected reference range and indicates
hypokalemia.
C. A urine specific gravity of 1.035 is above the expected reference range and indicates
concentrated urine.
D. A BUN level of 25 mg/dL is above the expected reference range and indicates the kidneys are
not excreting BUN as they should be.
3. The 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?
A. Play pat-a-cake
B. using a push pull toy
C. creating a scrapbook
D. playing dress-up
Answer: d
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. Playing pat-a-cake is a recommended play activity for an infant.
B. Using a push pull toy is a recommended play activity for a toddler.
C. Creating a scrapbook is a recommended play activity for a school-age child.
4. A nurse is teaching the parents of a newborn about ways to prevent sudden infant death
syndrome SIDS. Which of the following instructions should the nurse include?
A. Place the infant in a prone position to sleep.
B. Allow the infant to sleep on a large pillow.
C. User soft mattress in the infant's crib.
D. Give the infant a pacifier at bedtime.
Answer: d
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.
A. The nurse should instruct the parent to place the infant in a supine position to sleep. Prone and
side-lying positions are risk factors for SIDS.
B. Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation,
and SIDS.
C. The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds,
beanbags, or soft mattresses when placing the infant to bed. The use of a soft mattress in the
infant's crib is a risk factor for SIDS and can lead to asphyxiation.
5. 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?
A. Nasal flaring
B. WBC 11,300
C. diarrhea
D. abdominal distension
Answer: a
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse should place the
priority on nasal flaring. Nasal flaring indicates that the infant is experiencing acute respiratory
distress.
B. The nurse should report a WBC of 11,300/mm3 because it is above the expected reference
range and indicates infection. However, another finding is the priority for the nurse to report.
C. The nurse should report diarrhea because it is a manifestation of pneumonia in infants and
indicates the current treatment is not effective. However, another finding is the priority for the
nurse to report.
D. The nurse should report abdominal distension because it is a manifestation of pneumonia in
infants and indicates the current treatment is not effective. However, another finding is the
priority for the nurse to report.
6. A school nurse is assessing a school-age child blood pressure while he is seated in a chair. The
child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse
take first?
A. Clear the immediate area around the child of hazardous objects
B. loosen the child restrictive clothing
C. assist the child to a side-lying position on the floor
D. apply an oxygen mask to the child
Answer: c
Rationale:
The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling
out of the chair. The nurse should ease the child down to floor in a side-lying position
immediately. This position enables the child's secretions to drain from the mouth, preventing
aspiration, and maintaining a patent airway.
A. The nurse should clear the area around the child of hazardous objects.
However, this is not the first action the nurse should take.
B. The nurse should loosen the child's restrictive clothing. However, this is not the first action the
nurse should take.
D. The nurse should apply an oxygen mask to the child to prevent hypoxia.
However, this is not the first action the nurse should take.
7. A nurse is preparing to administer ibuprofen 5 mg per kg every 6 hours PRN for temperatures
above 38.0 degrees Celsius or 100.5 degrees Fahrenheit to an infant who weighs 17.6 lb. The
infant has a temperature of 38.4 degrees Celsius or 100 + 1.2 degrees Fahrenheit. Available is
ibuprofen liquid 100mg/ 5 ml. how many milli liters should the nurse administer to the infant per
dose? Round the answer to the nearest whole number. Use a leading zero if it applies.
Answer: 2 mL
Rationale:
Therefore, the nurse should administer 2 mL of ibuprofen per dose to the infant.
8. A nurse is receiving change-of-shift Report on for children. Which of the following children
should the nurse assesses first?
A. A toddler who has a concussion and an episode of forceful vomiting
B. an adolescent who has infective endocarditis and reports having a headache
C. an adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10
scale
D. school-age child who has acute glomerulonephritis and brown colored urine
Answer: a
Rationale:
When using the urgent vs. no urgent approach to client care, the nurse should assess this child
first. An episode of forceful vomiting is an indication of increased intracranial pressure in a
toddler who has a concussion.
B. A report of a headache is no urgent because it is an expected finding for a child who has
infective endocarditis; therefore, the nurse should assess another child first.
C. A report of moderate pain is no urgent because it is an expected finding for a child who has a
new halo traction device; therefore, the nurse should assess another child first.
D. Brown-colored urine is no urgent because it is an expected finding for a school-age child who
has acute glomerulonephritis; therefore, the nurse should assess another child first.
9. A nurse in the 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
Rationale:
A. is correct. The nurse should identify the lower right quadrant of the abdomen between the
umbilicus and the anterior iliac crest as the location of Burney’s point.
B. is incorrect. The nurse should not identify the left lower quadrant as the location of Mc
Burney's point.
C. is incorrect. The nurse should not identify the right upper quadrant as the location of
McBurney's point.
10. 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?
A. Limit the movement of the child large joints.
B. Encourage the child to perform independent self-care.
C. Provide the child with a soft mattress for sleeping.
D. Schedule a 2-hour daily nap for the child in the afternoon.
Answer: b
Rationale:
The nurse should teach the family the importance of encouraging the child to perform
independent self-care. This will minimize the child's pain while maximizing mobility.
Encouraging and praising the child's efforts for independence will also increase his self-esteem.
A. Large joints should be exercised regularly to maintain mobility and strengthen muscles.
C. Children who have juvenile idiopathic arthritis should sleep on a firm mattress to enhance
comfort and rest. A soft mattress can increase pressure to the affected joints and increase the
child’s pain.
D. Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity,
and naps can interfere with nighttime sleeping.
11. A nurse is assessing a client who has a new diagnosis of celiac disease. Which of the
following clinical manifestations should the nurse expect?
A. Steatorrhea
B. projectile vomiting
C. sunken abdomen
D. weight gain
Answer: a
Rationale:
The nurse should realize that clients who have celiac disease are unable to digest gluten. This
will cause damage to the cells in the bowel, leading to malabsorption, steatorrhea, and diarrhea.
B. Clients who have pyloric stenosis will exhibit projectile vomiting rather than celiac disease.
C. A distended abdomen, rather than a sunken abdomen, is a manifestation of celiac disease.
D. Weight loss, rather than weight gain, is a manifestation of celiac disease.
12. A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the
following statements by the Adolescent indicates an understanding of the teaching?
A. I should buy some plastic shoes to wear at the swimming pool
B. I should wear sandals as much as possible
C. I should place the permethrin cream between my toes twice-daily
D. I should I seal my non washable shoes in plastic bags for a couple of weeks
Answer: a
Rationale:
The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the
adolescent to avoid wearing plastic shoes.
B. Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the
medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing
sandals, open-toed, or well-ventilated shoes will promote healing of his fungal infection.
C. Permethrin 5% cream is a scabicide used to place on the lesions created by scabies. This
treatment is not recommended for tinea pedis.
D. Sealing non-washable items in plastic bags for 14 days is a recommended practice for clients
who have pediculosis. This practice is not recommended for tinea pedis.
13. Teaching the parents of a school-aged 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?
A. my child will have a cast until healing is complete.
B. My child will receive antibiotics for several weeks.
C. My child can return to playing sports once he is discharged.
D. My child needs to be in contact isolation.
Answer: b
Rationale:
The nurse should instruct the parent that the child will receive antibiotic therapy for at least
4weeks. Surgery might be indicated if the antibiotics are not successful.
A. incorrect
Weight bearing must be avoided with osteomyelitis. Therefore, the child is placed in comfortable
position with the limb supported. There is no indication for a cast.
C. incorrect
Weight bearing should be avoided to prevent complications and minimize pain. Therefore, it will
be several weeks to months before the child can play contact sports.
D. incorrect
Contact isolation is NOT necessary, because osteomyelitis is not a communicable illness.
14. A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify
the sound as which of the following? Click the audio button to listen.
A. Biots respiration
B. Chaney Stokes respiration
C. tackypnea
D. Bradypnea
Answer: c
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. Biot's respirations are periods of apnea alternating with two or three shallow breaths.
B. Cheyne-Stokes respirations are periods of apnea alternating with periods of hyperventilation.
D. Bradypnea is a slow, regular breathing pattern.
15. 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?
A. Elevate the head of the child's bed
B. insert a large-bore IV catheter for the child
C. determine the allergen that caused the child's reaction
D. administer IM epinephrine to the child
Answer: d
Rationale:
When using the urgent vs no urgent approach to client care, the nurse determines that the priority
action is administering IM epinephrine to the child. During an anaphylactic reaction, histamine
release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it
causes decreased blood return to the heart.
A. Elevating the head of the child's bed is important to facilitate breathing and circulation.
However, it is not the priority action the nurse should take.
B. Inserting a large bore IV catheter is important to facilitate administration of IV fluids and
medications. However, it is not the priority action the nurse should take.
C. Determining the allergen that caused the child's reaction is important to prevent any additional
episodes of anaphylaxis. However, it is not the priority action the nurse should take.
16. A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory
tract infection. Which of the following findings should the nurse recognize as a manifestation of
pertussis?
A. Inflamed throat with exudate
B. purulent eye drainage
C. dry, hacking cough
D. koplik spots on buccal mucosa
Answer: c
Rationale:
The nurse should recognize 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. An inflamed throat with exudate is a manifestation of acute streptococcal pharyngitis.
B. Purulent eye drainage is a manifestation of bacterial conjunctivitis.
D. Koplik spots on buccal mucosa are a manifestation of rubeola (measles).
17. A nurse is providing teaching about car seat use to the mother of a six-month- old infant.
Which of the following statements by the mother indicates an understanding of the teaching?
A. I should secure the car seat using lower anchors and tethers instead of the seat belt
B. I should position the car seat harness one inch above my baby's shoulders
C. I will make sure that the car seat is placed at a 90-degree angle
D. I will pad my baby's car seat with a blanket for traveling long distances
Answer: a
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 seatbelt does not have to be
used.
B. The car seat harness in rear-facing car seats should be positioned at or just below the infant’s
shoulders.
C. The car seat should be positioned at a 45-degree angle to prevent slumping and injury to the
infant.
D. Padding placed underneath the infant or anywhere in the car seat can compress and/or create
space between the infant and the harness. This could increase the risk for injury to the infant and
should be avoided.
18. A nurse is assessing the pain level of a three-year-old toddler. Which of the following pain
assessment scales should the nurse use?
A. FACES Pain rating scale
B. numeric pain rating scale
C. CRIES pain assessment scale
D. non communicating children's pain checklist
Answer: a
Rationale:
The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and
older. This scale allows the toddler to point to the face that depicts the current level of pain. The
nurse can then determine the need for pain management.
B. The nurse should use the numeric pain rating scale when assessing the need for pain
management in pediatric clients who are 5 years old and older. The nurse should identify that the
3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively
use this pain rating scale.
C. The nurse should use the CRIES pain assessment scale when assessing the need for pain
management in infants.
D. The nurse should use the noncommunicating children's pain checklist when assessing the need
for pain management in pediatric clients who have a cognitive impairment.
19. 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?
A. Apply topical antimicrobial ointment to the child wound
B. place a mesh gauze dressing over the child wound
C. administer an analgesic to the child
D. initiate prophylactic antibiotic therapy for the child
Answer: c
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. A nurse should apply topical antimicrobial ointment to the child's wound following
hydrotherapy to prevent infection.
B. A nurse should apply mesh gauze to the child's wound following hydrotherapy to prevent
infection.
D. Prophylactic antibiotic therapy is not recommended for children who have burns.
20. 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?
A. Urine specific gravity of 1.045
B. sodium 155
C. blood glucose 45
D. urine output 35 ml per hour
Answer: b
Rationale:
A child who has a head injury can develop diabetes insipidus as a result of pituitary hypo
function leading to a deficiency of antidiuretic hormone. Under excretion of antidiuretic
hormone leads to polyuria and polydipsia and possibly dehydration. With the excessive loss of
free water, sodium levels rise above the expected reference range.
A. Urine specific gravity of 1.045 is above the expected reference range. A child who has
diabetes insipidus is more likely to have diluted urine and urine specific gravity below the
expected reference range.
C. Blood glucose of 45 mg/dL is below the expected reference range. A child who has diabetes
insipidus should have a blood glucose level within the expected reference range.
D. Urine output of 35 mL/hr is within the expected reference range. A child who has diabetes
insipidus is more likely to have polyuria.
21. A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome
mcns and 3 + pitting edema. Which of the following interventions should the nurse include in the
plan?
A. Encourage an increased fluid intake for the toddler
B. place the child in an Airborne infection isolation room
C. increase the toddler's dietary sodium intake
D. administer corticosteroids to the toddler
Answer: d
Rationale:
The nurse should recognize that corticosteroids are the treatment of choice for providers caring
for children who have MCNS. Therefore, the nurse should include administration of prescribed
corticosteroids in the plan of care for this toddler.
A. Children who have MCNS are on dietary fluid restriction during the edema phase. Therefore,
the nurse should not encourage fluid intake for the toddler who has 3+ pitting edema.
B. Children who have MCNS do not require isolation precautions. Airborne infection isolation
room is used for clients who have airborne infections, such as tuberculosis.
C. Children who have MCNS are on a low-sodium diet during the edema phase. Therefore, the
nurse should not increase dietary sodium intake for the toddler who has 3+ pitting edema.
22. A nurse is providing discharge teaching to the parent of a school-age child who has moderate
persistent asthma. Which of the following instructions should the nurse include?
A. You should give your child his salmeterol inhaler every 4 hours when he is having an acute
episode of wheezing.
B. You should monitor your child's weight weekly while he is receiving inhaled corticosteroid
therapy
C. pulmonary function test will be performed every 12 to 24 months to evaluate how your child
is responding to therapy
D. when using the peak expiratory flow meter, record your child average of three readings
Answer: c
Rationale:
The nurse should inform the parent that her child will need pulmonary function tests every 12to
24 months to evaluate the presence of lung disease and how the child is responding to the current
treatment regimen. As children grow, sometimes their symptoms can improve or decline and
treatment needs to change accordingly.
A. salmeterol - The nurse should inform the parent that long-acting beta2 agonists are to be used
in conjunction with a low or medium dosage inhaled corticosteroid, and never used alone. Using
this medication alone on an as needed basis during an acute asthma attack is dangerous and can
lead to worsening of the child's condition.
B. The nurse should instruct the parent that the use of inhaled corticosteroids has not been shown
to have any negative effects on growth. The provider might monitor the child's growth for
systemic absorption; however, it is not necessary for the parent to weigh the child weekly.
D. The nurse should instruct the parent to measure the child's airflow using a peak expiratory
flow meter. This should be done twice daily with the skill repeated in a sequence of three,
waiting 30 seconds between each measurement. The parent should record the highest of the three
readings, rather than the average.
23. A nurse is assessing a three-year-old toddler visit. Which of the following manifestations
should the nurse report to the provider?
A. Blood pressure 90/ 50
B. respiratory rate 45/min
C. weight 14.5 kg or 32 lb
D. heart rate 110/min
Answer: b
Rationale:
A respiratory rate of 45/min is above the expected reference range 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 immediately.
A. A blood pressure of 90/50 mm Hg is within the expected reference range for a 3-yearoldtoddler.
C. A weight of 14.5 kg (32 lb) is within the expected reference range for a 3-year- old toddler.
D. A heart rate of 110/min is within the expected reference range for a 3-year-old toddler.
24. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions
should the nurse take?
A. Place a cardiac monitor on the Adolescent prior to the procedure
B. apply topical analgesic cream to the site one hour prior to the procedure
C. keep the Adolescent in a semi Fowler's position for 4 hours following the procedure
D. restrict fluids for 2 hours following the procedure
Answer: b
Rationale:
The nurse should apply a topical analgesic to the lumbar site 60 min prior to the procedure to
decrease the adolescent's pain while the lumbar needle is inserted.
A. Cardiac monitoring is not necessary during a lumbar puncture.
C. The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr to
prevent post procedural spinal headache.
D. The adolescent should be encouraged to drink extra fluids following the procedure to replace
the cerebrospinal fluid removed during the procedure.
25. A nurse is providing teaching to the parents of a toddler about the administration of a
prescribed eye drops and eye ointment. Which of the following instructions should the nurse
include?
A. Apply the eye ointment within 30 minutes of your toddler Awakening in the morning
B. apply the eye ointment from the outer canthus to the inner campus
C. use one hand to pull the upper eyelid upward when instilling the eye drops
D. administer the eye drops 3 minutes before the ointment
Answer: d
Rationale:
The nurse should instruct the parents to administer the eye drops first and then wait 3 min before
administering the eye ointment. This action provides adequate time and spacing for each separate
medication to work.
A. The nurse should instruct the parents to administer the eye ointment prior to a nap or bedtime
since the medication can cause temporary blurred vision.
B. The nurse should apply the eye ointment from the inner canthus to the outer canthus to
prevent the entry of infectious organisms into the lacrimal duct.
C. The nurse should instruct the parents to use one hand to pull the lower eyelid downward when
instilling the eye medication to ensure placement of the medication in the conjunctival sac.
26. The nurse is providing discharge teaching to the parent of an 18-month old toddler who has
dehydration as a result of acute diarrhea. Which of the following statements by the parent
indicates an understanding of the teaching?
A. I will offer my child small amounts of fruit juice frequently
B. I will avoid giving my child solid foods until his diarrhea has stopped
C. I will monitor my child's number of wet diapers
D. I will give my child polyethylene glycol daily for 7 days
Answer: c
Rationale:
The nurse should teach the parent to closely monitor the child's number of wet diapers.
Monitoring the number of wet diapers per day is the best way for the parent to monitor adequate
output and hydration status.
A. Children recovering from dehydration should not be encouraged to drink frequent, small
amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high
osmolality value.
B. The nurse should teach the parent to encourage solid foods even when the child has diarrhea.
D. Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the
frequency of stools, which will increase the level of dehydration.
27. 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?
A. Obtain a sputum specimen
B. perform an allen test
C. perform a finger stick
D. obtain a stool specimen
Answer: c
Rationale:
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.
A. Sputum specimens are collected to identify the infectious organism in a child who has as
acute respiratory tract infection. Therefore, this is not a component of the sickle-turbidity test.
B. An Allen test determines adequate circulation by observing capillary refill before an arterial
puncture. Therefore, this is not a component of the sickle-turbidity test.
D. Stool specimens are collected to identify organisms or parasites that cause diarrhea or to
check for the presence of occult blood. Therefore, this is not a component of the sickle-turbidity
test.
28. A nurse is caring for a school-age child who has peripheral edema. Which of the following
assessments should the nurse perform to confirm peripheral edema?
A. Palpate the dorsum of the child's feet
B. play the child daily using the same scale
C. assess the child's skin turgor
D. observe the child for periorbital swelling
Answer: a
Rationale:
The nurse should palpate the dorsum of the feet by pressing her fingertip against a bony
prominence for 5 seconds to assess for peripheral edema.
B. Weighing the child daily might indicate that the child has retained fluid; however, this is not
an acceptable method for assessing for peripheral edema.
C. Assessing the child's skin turgor measures the elasticity and mobility of the skin; however, this
is not an acceptable method for assessing for peripheral edema.
D. Observing the child for periorbital swelling is an appropriate method for assessing central
edema; however, this is not an acceptable method for assessing for peripheral edema.
29. A nurse in the emergency department is caring for a toddler who has partial thickness burns
on his right arm. Which of the following actions should the nurse take?
A. Insert a nasogastric tube
B. initiate prophylactic antibiotics therapy
C. cleanse the affected area with mild soap and water
D. apply a topical corticosteroid to the affected area
Answer: c
Rationale:
The nurse should wash the affected area with mild soap and water to remove any loose tissue that
could cause infection.
A. Inserting a nasogastric tube to empty the contents of the stomach and maintain decompression
is an intervention for major burn management.
B. Prophylactic antibiotics are not recommended for burns of any type.
D. The nurse should apply an antibiotic ointment to the affected area to prevent infection.
30. A nurse is performing hearing screenings for children at a community health fair. Which of
the following children should the nurse refer to a provider for a more extensive hearing
evaluation?
A. A toddler who is 18 months old and has unintelligible speech
B. an infant who is 3 months old and has an exaggerated startle response
C. a preschooler who is 4 years old and prefers playing with others rather than alone
D. an infant who is 8 months old and is not yet making babbling sounds
Answer: d
Rationale:
The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a
provider for more extensive evaluation of hearing.
A. The nurse should refer a toddler who does not possess intelligible speech by the age of 24
months to a provider for more extensive evaluation of hearing.
B. The nurse should refer infants who are under the age of 4 months and lack a startle response
to a provider for more extensive evaluation of hearing.
C. The nurse should refer a preschooler who prefers playing alone and avoids interaction with
others to a provider for more extensive evaluation of hearing.
31. A nurse is providing dietary teaching to the parent of a school-age child who has cystic
fibrosis. Which of the following statements should the nurse make?
A. You should offer your child high protein meals and snacks throughout the day
B. your child should decrease dietary fats to less than 10% of her caloric intake
C. your child will need to take a 1-gram sodium chloride tablet daily throughout her lifetime
D. you should calculate your child carbohydrate needs based on her daily activities
Answer: a
Rationale:
The parent should provide a diet that is well-balanced and high in protein and calories. Children
who have cystic fibrosis require a higher percentage of the recommended dietary allowances of
all nutrients in order to meet their energy requirements. Children who have good nutritional
intake have improved lung function and decreased risk of infection.
B. Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require
35%to 40% of their calories to come from fats.
C. Children who have cystic fibrosis are at risk for losing sodium and chloride through
perspiration, especially when the weather is hot. The parent should monitor the child during hot
weather and ensure adequate fluid intake. There is no need for the child to take supplemental
sodium chloride tablets, because the child's regular diet should provide adequate amounts.
D. Children who have cystic fibrosis need to eat a diet high in calories, protein, and
carbohydrates. Children who have diabetes mellitus usually calculate carbohydrate needs
according to their daily activities.
32. The nurse is providing 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 tote
child?
A. Wheat bread
B. vanilla malt
C barley soup
D. rice pudding
Answer: d
Rationale:
The nurse should instruct the parent that the child will remain on a lifelong gluten- free diet. The
child cannot consume oats, rye, barley or wheat, and sometimes lactose deficiency can be
secondary to this disease. The nurse should recognize that rice pudding is a gluten-free food.
Therefore, it is an acceptable choice for the nurse to recommend to the parent of a child who has
celiac disease.
A. Wheat bread contains gluten and should be avoided by children who have celiac disease.
B. Malt contains gluten and should be avoided by children who have celiac disease.
C. Barley soup contains gluten and should be avoided by children who have celiac disease.
33. A nurse is providing teaching to the parents of a preschooler who has heart failure and who is
to begin taking Digoxin twice-daily. Which of the following instructions should the nurse include
in the teaching?
A. Use a kitchen teaspoon to measure the medication
B. brush the child teeth after giving the medication
C. double the next dose If the child misses a dose
D. repeat the dose If the child vomits
Answer: b
Rationale:
The nurse should instruct the parents to brush the child's teeth after administering digoxin to
prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the
taste.
A. The nurse should instruct the parents to use the calibrated device that comes with the
medication when measuring the medication to avoid accidental overdose.
C. The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr.
The nurse should instruct the parents not to double the medication amount if they miss a dose
because this can result in digoxin toxicity.
D. Nausea, vomiting, and decreased appetite are common manifestations of digoxin toxicity in
children. The nurse should instruct the parents not to administer a second dose if the child vomits
and to notify the provider.
34. A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and
is to begin taking oral Nystatin. Which of the following instructions should the nurse include?
A. Check the medication prior to Administration
B. provide the medication through a straw
C. rinse the child mouth with water immediately after giving the medication
D. next the medication with applesauce If the child dislikes the taste
Answer: a
Rationale:
The nurse should instruct the parent to shake the medication prior to administration in order to
disperse the medication evenly within the suspension.
B. The nurse should instruct the parent to put the medication directly in the child's mouth and
make sure the child swishes it around before swallowing.
C. The nurse should instruct the parent to have the child keep the medication in his mouth for as
long as possible before swallowing it. Rinsing his mouth can wash some of the medication away
and decrease effectiveness.
D. The parent should not mix the medication with food because this will interfere with the
absorption.
35. The 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?
A. Controls impulsive feelings
B. understand right from wrong
C. usually separated from parents for a long periods of time
D. expresses likes and dislikes
Answer: d
Rationale:
The nurse should teach the mother that her toddler will begin to express her likes and dislikes.
This is the time in life when a toddler is developing autonomy and self-concept. She will try to
assert herself and frequently refuse to comply. The parent should allow the child to have some
control but also set limits in order for her to learn from her behavior and learn to control her
actions.
A. The mother should expect a school-age child to be able to control impulsive feelings. A
toddler is more likely to have difficulty controlling strong and impulsive feelings as she tries to
assert her independence and gain control of situations.
B. The mother should expect a preschooler to begin to understand right from wrong and to
modify her behavior in response to others' expectations. A toddler has a great deal of curiosity
and asks many questions but is not able to fully understand what behaviors are right or wrong.
C. The mother should expect that her toddler might be able to separate from her for a short
period of time, but the toddler is more likely to experience acute separation anxiety when
separated from her mother for an extended time. The toddler might offer resistance if she is left
with a new babysitter or at a new day care center.
36. The 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?
A. Hematocrit 28%
B. hemoglobin 13.5 g
C. WBC 8000
D. platelet 250,000
Answer: a
Rationale:
The nurse should recognize that this hematocrit level is below the expected reference range fora
school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor
due to the decreased oxygen- carrying capacity.
B. This hemoglobin level is within the expected reference range for a school-age child.
C. This WBC is within the expected reference range for a school-age child.
D. This platelet is within with expected reference range for a school-age child.
37. A nurse is creating a plan of care for an infant who has an epidural hematoma with a
skullfracture. Which of the following actions should the nurse include in the plan?
A. Position the infant side lying with her head at a 0 - 5 degree angle
B. monitor the infant for tachycardia to prevent brain stem herniation
C. suction the infant snares every two hours while awake to maintain patency
D. implements seizure precautions for the infants
Answer: d
Rationale:
The nurse should implement seizure precautions for an infant who has an epidural hematomas’ a
safety measure.
A. The nurse should position the infant with her head elevated in a midline position to reduce the
risk of increased intracranial pressure.
B. The nurse should monitor for indications of brainstem herniation, which include Cushing'
striad: hypertension, bradycardia, and decreased respirations.
C. The nurse should avoid suctioning the infant's nares due to the risk of exposure of the suction
catheter to the brain through the fracture.
38. A nurse in an emergency department is performing a physical assessment on a 2-week old
male infant. Which of the following manifestations is the priority for the nurse to report to the
provider?
A. Excoriated scrotal area
B. multiple capillary hemangiomas
C. depressed posterior fontanel
D. substernal retractions
Answer: d
Rationale:
When using the airway, breathing, 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 infant is experiencing acute respiratory distress and increased respiratory effort, which could
quickly progress to respiratory failure.
A. The nurse should report an excoriated scrotal area to the provider. However, this is not the
priority finding.
B. The nurse should report the presence of multiple capillary hemangiomas to the provider.
However, this is not the priority finding.
C. The nurse should report a depressed posterior fontanel. However, this is not the priority
finding.
39. A nurse is providing discharge teaching to the parents of a three-month-old infant following
acheiloplasty. which of the following instructions should the nurse include?
A. Clean your baby's sutures daily with a mixture of chlorhexidine and water
B. expect your baby to swallow more than usual over the next few days
C. inspect your baby's tongue for white patches using a tongue depressor every 8 hours
D. apply a thin layer of antibiotic ointment on your babies’ suture line daily for the next three
days
Answer: d
Rationale:
The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant’s
suture line daily for 3 days and then continue to apply petroleum jelly to the area for several
weeks to promote healing.
A. The parents should clean the infant's sutures with sterile water or diluted hydrogen peroxide
following each feeding.
B. Excessive swallowing is an indication of bleeding and should be reported to the provider
immediately.
C. The parents should avoid placing objects, such as tongue depressors, in the infant's mouth to
prevent injury to the suture line.
40. A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few
hours while another relative stay with the child. Which of the following statements should the
nurse make to explain to the child when her mother will return?
A. Your mommy will be back at 7 p.m.
B. your mommy will be back after she takes care of your brother
C. your mommy will be back in the morning
D. your mommy will be back after you eat
Answer: d
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.
A. A preschooler does not have an accurate understanding of time. They use language, but most
of the time they do not actually know or conceive the meaning of the words.
B. A preschooler does not have an accurate understanding of time. They use language, but most
of the time they do not actually know or conceive the meaning of the words. Also, this response
by the nurse does not relate to the child directly.
C. A preschooler does not have an accurate understanding of time. They use language, but most
of the time they do not actually know or conceive the meaning of the words.
41. A nurse is planning developmental activities for a newly admitted 10-year-old child who has
neutropenia. Which of the following actions should the nurse plan to take?
A. Provide the child with a book about Adventure
B. arrange frequent visits from family members and peers
C. give the child a large piece puzzle
D. use puppet to entertain the child
Answer: a
Rationale:
The nurse should provide a school-age child with a book about adventure as a developmental
activity because children are expanding their knowledge and imagination during this age.
Through reading, school-age children can feel powerful and skill ful as they imagine themselves
in the stories they read.
B. The nurse should limit visitors for a child who has neutropenia because this places the child at
an increased risk of infection.
C. The nurse should provide a large-piece puzzle to a preschooler. School-age children desire
Tobe mentally challenged with complex board and video games.
D. The nurse should use puppets to entertain toddlers. A school-age child would not be
entertained for very long or mentally challenged with puppets. They prefer complex board and
video games.
42. A nurse in the emergency department is caring for a school-age child who has epiglottitis.
Which of the following actions should the nurse take?
A. Obtain a throat culture from the child
B. monitor the child's oxygen saturation
C. put a warm mist humidifier in the child's room
D. Place the child in a Supine position
Answer: b
Rationale:
The nurse should monitor the child's oxygen saturation level because the child is experiencing
acute respiratory distress and it is necessary to determine if the child is responding to treatment.
A. Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse
should wait until an airway is established for the child before performing any diagnostic testing.
C. The nurse should administer humidified oxygen by face mask or blow-by, rather than place a
warm mist humidifier in the child's room.
D. Placing the child in the supine position increases the child's risk for a complete airway
obstruction. The nurse should place the child in an upright position, and sometimes it is helpful
for the child to lean over the bedside table to help with breathing.
43. A nurse in an Emergency Department is assessing a three-month-old infant who has
rotavirusand is experiencing acute vomiting and diarrhea. Which of the following manifestations
should the nurse identify as an indication that the infant has moderate to severe dehydration?
A. Heart rate 124/ minute
B. increase tear production
C. sunken anterior fontanel
D. capillary refill 2 seconds
Answer: c
Rationale:
The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe
dehydration due to the acute loss of fluid.
A. A heart rate of 124/min is within the expected reference range of 106 to186/min for a 3- to5month-old infant. The nurse should expect the infant who has moderate to severe dehydration to
have tachycardia.
B. An infant who has moderate to severe dehydration is more likely to have absence of tears,
rather than increased tear production.
D. Capillary refill of 2 seconds is within the expected reference range for a 3- month-old infant.
An infant who has moderate to severe dehydration is more likely to have delayed capillary refill
of greater than 2 seconds.
44. A nurse is creating a plan of care for a newly admitted adolescent who has bacterial
meningitis. How long should the nurse plan to maintain the Adolescent in droplet precautions?
A. Until the Adolescent is afebrile
B. for 7 days following an admission to the facility
C. until the Adolescent has a negative blood culture
D. for 24 hours following initiation of antimicrobial therapy
Answer: d
Rationale:
The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr
following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no
longer contagious, which protects family members and the personnel caring for the client.
Prophylactic antibiotics might be prescribed to individuals who were in close contact with the
adolescent.
A. A temperature within the expected reference range for an adolescent can be achieved with
acetaminophen. Therefore, this is not a determinant factor for removing a client from droplet
precautions.
B. The adolescent is not contagious for 7 days. Therefore, it is not necessary for the nurse to
maintain droplet precautions for that length of time.
C. Blood cultures should be drawn before the first dose of antibiotics. It usually takes 48 to 72 hr
for the organism to grow enough for identification. The test should be repeated after the entire
antibiotic regimen is completed to determine if the infection is still present. Therefore, blood
cultures are not a determinant factor for removing a client from droplet precautions.
45. A school nurse is assessing an adolescent who presents with multiple Burns in various stages
of healing. Which of the following behaviors should the nurse identify as suggestive of possible
physical abuse?
A. Expresses a reluctance to leave home
B. provides a detailed description of how the burns occurred
C. denies discomfort during assessment of injuries
D. describes strong relationships with peers
Answer: c
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. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent
expresses a reluctance to return home, or demonstrates a fear of parents.
B. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent’s
description of the injury is vague and incompatible with the actual wounds.
D. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent
has withdrawn behavior and poor relationships with peers.
46. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema.
Which of the following findings indicates effectiveness of the medication?
A. The Adolescents reports in absence of nausea and vomiting
B. the client experiences onset of loose stools within 15 minutes of administration
C. The Adolescents serum potassium level is 4.1
D. the Adolescent has a blood pressure of 86/ 52
Answer: c
Rationale:
The nurse should monitor the adolescent's serum potassium level following the administration of
sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging
sodium ions for potassium ions in the intestine.
Therefore, a potassium level within the expected reference range indicates the effectiveness of
the medication.
A. Absence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium
polystyrene sulfonate is an antidote which exchanges sodium ions in the intestine. Therefore,
absence of nausea and vomiting is not an indicator of medication effectiveness.
B. The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium
polystyrene sulfonate.
D. A blood pressure of 86/52 mm Hg is below the expected reference range for an adolescent and
does not indicate the effectiveness of the medication. The nurse should continue to monitor blood
pressure as an indicator of fluid and electrolyte imbalance.
47. 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?
A. Instruct the parents to decrease the calcium in their toddler's diet
B. prepare the toddler for chelation therapy
C. refer at the family to Child Protective Services
D. schedule the toddler for a yearly rescreening
Answer: d
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. The nurse should instruct the toddler's parents to provide a diet rich in calcium because
calcium, vitamin C, and iron decrease lead absorption.
B. Chelation therapy is required for a lead level of 45 mcg/dL or greater and, depending on the
situation, can be initiated for lead levels over 10 mcg/dL.
C. A serum lead level of 4 mcg/dL does not require a report to Child Protective Services because
it is not an indicator of child endangerment.
48. A nurse is assessing a school-age child immediately post-operative following a perforated
appendix repair. Which of the following findings should the nurse expect?
A. Purulent nasogastric drainage
B. absence of peristalsis
C. passage of dark red stool with mucus
D. WBC of 6000
Answer: b
Rationale:
The nurse should expect absence of peristalsis in the immediate postoperative period, until the
bowel resumes functioning.
A. Purulent drainage is not an expected finding postoperatively. Clear to green- tinged is the
expected color of the drainage from the NG tube.
C. Passage of dark red stool with mucus is not an expected finding immediately post operative.
This finding is a clinical manifestation of Meckel diverticulum.
D. This level is below the expected reference range. A WBC greater than 10,000/mm3 is an
expected finding in a client who has had a ruptured appendix.
49. A nurse is teaching the parents of a toddler who has cognitive impairment about toilet
training. which of the following instructions should the nurse include in the teaching?
A. Scold the child when he has a toileting accident
B. award the child with a sticker when he sits on the potty chair
C. play the child favorite song while teaching him to use the potty chair
D. teach multiple steps of the skill at the same time
Answer: b
Rationale:
The child with a cognitive impairment learns through shaping behaviors. The parents should
reward the child for sitting on the potty chair as a reinforcement of the 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. The parents should use positive reinforcement when teaching their child a new task.
Reinforcing positive behaviors, such as remaining dry through the night, will have a greater
impact on the child than the negative reinforcement of scolding.
C. A child who has a cognitive impairment has difficulty discriminating between two or more
cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching
the child the task of toilet training.
D. The nurse should instruct the parents to teach one step at a time to the child. Children who
have a cognitive impairment are less able to remember multiple steps. The child should master
each step before the parents introduce the next step.
50. A nurse in a provider's office is caring for a school-age child who has varicella. The parent
ask the nurse when her child will no longer be contagious. Which of the following responses
should the nurse make?
A. When your child no longer has an increased temperature
B. three days after you first noticed the rash appear on your child
C. when your child lesions are crusted, 6 days after they appear
D. 2 - 3 weeks, when your child's lesions completely disappear
Answer: c
Rationale:
The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and
until the vesicles have crusted over, which usually takes about 6 days.
A. The nurse should inform the parent that an absence of a fever does not indicate the child is no
longer contagious.
B. The nurse should inform the parents that the child will remain contagious longer than three
days after the lesions appear.
D. The incubation period of varicella is two to three weeks. However, this is not related to the
appearance and disappearance of the lesions.
51. A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking
prednisone. Following one week of treatment, which of the following clinical manifest ations
indicate to the nurse that the medication is effective?
A. Decrease edema
B. increased abdominal girth
C. decreased appetite
D. increased protein in the urine
Answer: a
Rationale:
A child who has nephrotic syndrome can experience edema due to the increased glomerular
permeability, which increases protein loss. Prednisone decreases glomerular permeability, which
causes fluid to shift from the extracellular spaces, decreasing edema.
B. The nurse should expect decreased abdominal girth with prednisone therapy.
C. Increased, rather than decreased, appetite is an expected manifestation of cortico steroid
therapy.
D. The nurse should expect decreased protein in the urine with prednisone therapy.
52. A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the
following clinical manifestations should the nurse expect? Select all that apply.
A. Negative Babinski reflex
B. Ankle clonus
C. exaggerated stretch reflexes
D. uncontrollable movements of the face
E. contractures
Answer: B C E
Rationale:
Negative Babinski reflex is incorrect. A child who has spastic cerebral palsy will exhibit a
positive Babinski reflex.
Ankle clonus is correct. A child who has spastic cerebral palsy will exhibit ankle clonus which
isa rhythmic reflex tremor when the foot is dorsiflexed.
Exaggerated stretch reflexes is correct. A child who has spastic cerebral palsy will exhibit
spasticity or exaggerated stretch reflexes.
Uncontrollable movements of the face is incorrect. Uncontrollable movements of the face and
extremities are manifestations of nonspastic (dyskinetic) cerebral palsy, rather than spastic
(pyramidal) cerebral palsy.
Contractures is correct. A child who has spastic cerebral palsy will exhibit contractures due to the
tightening of the muscles.
53. A nurse is assessing the vital signs of a 10 year old child following a burn injury. Which of
the following clinical manifestations indicate early septic shock?
A. Blood pressure 130/ 90
B. heart rate 60/ Minute
C. temperature 39.1 degrees Celsius or 102.4 degrees Fahrenheit
D. urinary output 100 mL/hr
Answer: c
Rationale:
The nurse should expect a child who has early septic shock to have a fever and chills.
A. A blood pressure of 130/90 mm Hg is above the expected reference range for a 10-yearoldchild. The nurse should expect a child who has early septic shock to have a blood pressure
within the expected reference range.
B. A heart rate of 60/min is below the expected reference range for a 10-year-old child. The nurse
should expect a child who has early septic shock to have a heart rate within the expected
reference range.
D. Urinary output of 100 mL/hr is above the expected reference range for a 10- year-old child.
The nurse should expect a child who has early septic shock to have urinary output within the
expected reference range.
54. A nurse is creating a plan of care for a preschooler who has Wilms tumor and is scheduled for
surgery. Which of the following interventions should the nurse include?
A. Avoid palpating the abdomen when bathing the child before surgery
B. refrain from auscultating the child bowel sounds during the post-operative assessment
C. encourage the child to play with other children on the unit prior to surgery
D. explain it to the child that his pain will be managed after the surgery
Answer: a
Rationale:
The nurse should avoid palpating the abdomen when bathing the child before surgery because
movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant
to the tumor site.
B. Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of
the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the
surgery.
C. The child's risk for injury increases with physical activity. Therefore, the nurse should no ten
courage the child to play with other children on the unit.
D. Telling the child about pain prior to surgery will likely increase his fear and anxiety level.
Therefore, the nurse should not explain to the child that pain will be managed after surgery.
55. 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
clinical manifestations should the charge nurse include as suggestive of potential physical abuse?
A. Recurrent urinary tract infections
B. symmetric Burns of the lower extremities
C. growth failure
D. lack of subcutaneous fat
Answer: b
Rationale:
The nurse should include in the teaching that symmetric burns of the lower extremities are a
suggestive clinical manifestation of 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. Recurrent urinary tract infections are a suggestive clinical manifestation of sexual abuse.
C. Growth failure is a suggestive clinical manifestation of physical neglect due to malnutrition.
D. Lack of subcutaneous fat is a suggestive clinical manifestation of physical neglect. This
manifestation is likely a result of poor healthcare, infections that were untreated, and/or a lack of
or delayed childhood immunizations.
56. The 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?
A. sodium 148
B. urine specific gravity of 1.020
C. mental confusion
D. weak peripheral pulses
Answer: c
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.
A. A sodium level of 148 mEq/L is above the expected reference range for a 15- year-old
adolescent. SIADH is caused by the secretion of excess antidiuretic hormone, which results in
adecreased serum sodium level due to increased circulation of free water.
B. A urine specific gravity of 1.020 is within the expected reference range. A child who has
SIADH is more likely to have concentrated urine and urine specific gravity above the expected
reference range.
D. A child who has SIADH is more likely to have fluid overload, full, bounding pulses, increased
blood pressure, and tachycardia.
57. A nurse in a provider's office is preparing to administer immunizations to a toddler during a
well-child visit. Which of the following actions should the nurse plan to take?
Prescriptions: tuberculin skin test
TST measles mumps rubella
vaccine inactivated influenza
vaccine
diphtheria, tetanus, and pertussis DTaP
vaccine Vital signs
respiratory rate 24/
minute heart rate 115/
minute
temperature 37.4 degrees Celsius or 99.3 degrees
Fahrenheit History and physical
Age 12 months is 9
Days height 71.1 CM
or 28-in
allergies neomycin - anaphylactic reaction
caregiver reports rhinitis with clear nasal drainage for 2
days occasional non productive cough for 2 days
history of asthma
A. Withhold the measles mumps and rubella MMR vaccine
B. withhold the DTaP vaccine
C. withhold the influenza vaccine
D. withhold the tuberculin skin test TST
Answer: a
Rationale:
The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a
contraindication to receiving the MMR vaccine. Clients who have a severe allergy to eggs
orgelatin should not receive this vaccine.
B. It is safe to administer the DTaP vaccine at the same time as the MMR vaccine and TST. DTa
Pvaccines are not contraindicated in children who have mild acute illness or asthma.
C. A child who has asthma can take the inactivated influenza vaccine.
D. It is safe to perform a TST at the same time as administering MMR and varicella vaccines.
ATST is not contraindicated in children who have mild acute illness or asthma.
58. A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV
catheter. When preparing a to discontinue the IV fluids and catheter, which of the following
actions should the nurse plan to take? Place the steps in order of performance.
A. remove the tape securing the catheter
B. turn off the IV pump
C. occlude the IV tubing
D. apply pressure over the catheter insertion site
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:
1. Turn off the IV pump: This is the first step to prevent any additional fluids from entering the
catheter once it is removed.
2. Occlude the IV tubing: By occluding the tubing, the nurse prevents any backflow of blood or
fluids from the patient's vein once the catheter is removed.
3. Remove the tape securing the catheter: Removing the tape allows for easier removal of the
catheter from the skin.
4. Apply pressure over the catheter insertion site: Applying pressure helps to prevent bleeding
and promote clotting at the insertion site once the catheter is removed.
Following these steps ensures a safe and effective removal of the IV catheter.
59. A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. the
nurse should identify that which of the following menu items has the highest amount of iron?
A. ½ cup whole milk
B. 1 cup orange juice
C. ½ cup raisins
D. one cup raw carrots
Answer: c
Rationale:
The nurse should encourage the adolescent to eat raisins because they contain the highest amount
of nonheme iron.
A. Whole milk does not contain the highest amount of iron.
B. Orange juice does not contain the highest amount of iron. However, it does contain ascorbic
acid, which increases the amount of nonheme iron absorbed by the body.
D. Raw carrots do not contain the highest amount of iron.
60. A nurse is creating an educational plan to teach parents about protecting their children from
sun burns. Which of the following instructions should the nurse plan to include?
A. Choose a waterproof sunscreen with an SPF of at least 15
B. apply sunscreen liberally to infants over three months of age
C. dress children in a loose weave polyester fabric prior to sun exposure
D. reapply sunscreen every 4 hours
Answer: a
Rationale:
The nurse should instruct parents to apply a waterproof sunscreen with an SPF of at least 15 for
children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of
sunburn.
B. The nurse should instruct parents to avoid the liberal application of sunscreen on infants under
the age of 6 months. Parents should only apply sunscreen on infants under 6 months to small
areas of exposed skin and should take other measures to reduce or prevent sun exposure.
C. The nurse should instruct parents to dress their children in a tight weave cotton fabric prior to
sun exposure to protect the skin.
D. The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
