Preview Extract
ATI PEDS NURSING CARE OF CHILDREN PROCTORED EXAM 2023/2024 NEXT
GEN FORMAT NGN VERIFIED AND ACCURATE WITH DETAILED ANSWERS
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1. A nurse reviews the laboratory result of a preschooler who has gastroenteritis and notes the
client's potassium level is 3.2 mEq/L. Which of the following assessment findings should the
nurse expect?
A. Hypertension
B. Oliguria
C. Hyporeflexia
D. Hyperactive bowel sounds.
Answer: B. Oliguria
2. A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization
procedure. Which of the following findings should the nurse report to the provider?
A. Bilateral extremities
B. Weak pedal pulse distal to the site
C. Serum glucose 90 mg/dl
D. Blood pressure 102/58 mm Hg.
Answer: B. Weak pedal pulse distal to the site
3. A school nurse is assessing a 7 year old student. The nurse should identify which of the
following findings is a potential indicator of physical abuse?
A. Abrasions on the knees
B. Front deciduous teeth missing
C. Weight in 45th percentile
D. Bruising around the wrists
Answer: D. Bruising around the wrists
4. A nurse is teaching the parents of a school-age child about bicycle safety. Which of the
following instructions should the nurse include in the teaching?
A. Your child should walk the bicycle through intersections
B. Your child should keep the bicycle at least 3 feet from the curb while riding in the street.
C. Your child should ride the bicycle against the flow of traffic
D. Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle.
Answer: A. Your child should walk the bicycle through intersections
5. A charge nurse is teaching a group of nurses about identifying child abuse. Which of the
following findings should the nurse identify as a potential indicator of child abuse?
A. A toddler repeatedly refuses to let a nurse auscultate his lungs
B. A toddler has bruises on his knees.
C. An 8-month-old infant cries when his parent levels the room.
D. A mother is hesitant to comfort her 6-month-old infant.
Answer: D. A mother is hesitant to comfort her 6-month-old infant.
6. A nurse is teaching the guardian of 5- years old child who has encopresis (fecal
incontinence) about managing the condition. Which of the following statements by the
guardian indicates an understanding of the teaching?
A. I will limit my child's fluid intakes
B. I will increase my child's diary intakes
C. I will have my child try to defecate 15 minutes after each meal
D. I will have my child sit on the toilet for 20 minutes at a time.
Answer: C. I will have my child try to defecate 15 minutes after each meal
7. A nurse is preparing to initiate IV antibiotics therapy for a newly admitted 12-month-old
infant. Which of the following actions should the nurse plan to take?
A. Cover the insertion site with an opaque dressing.
B. Use a 24-gauge catheter to start the IV.
C. Start the IV in the infant's foot.
D. Change the IV site every 3 days.
Answer: B. Use a 24-gauge catheter to start the IV.
8. A nurse is caring for a postoperative client following placement of a halo vest to manage a
cervical vertebral fracture. Which of the following actions should the nurse take?
A. Tighten the screws on the halo device one quarter turn every 48 hr
B. Reposition the client using a turning sheet
C. Assess the pin sites for infection once every other day. (suppose to be everyday)
D. Encourage flexion and extension of the neck.
Answer: B. Reposition the client using a turning sheet
9. A nurse is planning care for an adolescent following repair of the Meckel diverticulum.
Which of the following actions should the nurse include in the plan of care?
A. Teach the client about ostomy care
B. Indicate long-term antibiotic therapy.
C. Administer total parenteral nutrition.
D. Maintain an NG tube for decompression.
Answer: D. Maintain an NG tube for decompression.
10. A nurse is caring for a school-age child who has pertussis. Which of the following actions
should the nurse take?
A. Restrict oral fluids to 500 mL per day.
B. Administer the pertussis vaccine.
C. Report the diagnosis to the public health department. (CDC)
D. Place the child in a protected environment for 48 hr.
Answer: C. Report the diagnosis to the public health department. (CDC)
11. A nurse in the emergency department cares for a school-age child who has developed
respiratory stridor, wheezing, and urticaria after receiving an IV medication. Which of the
following actions should the nurse take first?
A. Administer oxygen.
B. Administer epinephrine
C. Administer methylprednisolone.
D. Administer a nebulizer bronchodilator.
Answer: B. Administer epinephrine
12. A nurse is teaching a group of female adolescents about healthy eating. Which of the
following instructions should the nurse include in the teaching?
A. Increase the amount of your dietary iron intake
B. limit your sodium intake to 3000 mg per day
C. consumer 1,500 to 1700 calories per day
D. decrease your vitamin K intake once you start to menstruate Increase the amount of your
dietary iron intake
Answer: A. Increase the amount of your dietary iron intake
13. A nurse is assessing a child who has multiple Closed fractures of the lower extremities
due to a motor vehicle crash. The nurse should monitor the child for which of the following
complications during the first 24 hours after the injury occurred?
A. Compartment syndrome
B. Osteomyelitis
C. Renal calculi
D. Volkmann ischemic contracture.
Answer: A. Compartment syndrome
14. A nurse in an emergency department is caring for a preschool-age child who has acute
acetylsalicylic acid poisoning. Which of the following should the nurse expect?
A. Neck vein distention
B. Jaundice
C. Polyuria
D. Hyperpyrexia
Answer: D. Hyperpyrexia
15. A nurse is assessing a toddler who has a history of lead poisoning. Which of the
following actions should the nurse take?
A. Inspect the skin for discoloration
B. Initiate a low diet for lead absorption
C. Obtain a stool specimen for lead levels
D. Perform development testing for delays
Answer: D. Perform development testing for delays
16. A nurse teaches about growth and development to a parent of a 12- years old child. The
nurse should instruct the parent to expect the child to exhibit the following characteristics
during early adolescence?
A. Emotional separation from parents
B. Decelerating growth rate.
C. Mood swings
D. Increased self-esteem.
Answer: C. Mood swings
17. A nurse is educating an adolescent following the application of an arm cast. Which of the
following statements by the client indicates an understanding of the teaching?
A. I should limit the use of the fingers of my broken arm
B. I will sprinkle the baby powder into the cast if my arm itches
C. I will elevate my broken arm on pillows at night.
D. I should expect my fingers to be swollen for several days.
Answer: C. I will elevate my broken arm on pillows at night.
18. A nurse is planning to teach an adolescent who is lactose intolerant about dietary
guidelines. Which of the following instructions should the nurse include in the teaching?
A. You should consume flavored yogurt instead of plain yogurt
B. You can replace milk with non-dairy sources of calcium
C. You might tolerate plain milk better than chocolate milk
D. You can drink milk on an empty stomach.
Answer: B. You can replace milk with non-dairy sources of calcium
19. A nurse is admitting a child who has acute epiglottitis. Which of the following actions
should the nurse take?
A. Obtain a throat culture
B. Check oxygen saturation every 4 hr.
C. Initiate droplet isolation precautions.
D. Assist the child in a supine position.
Answer: C. Initiate droplet isolation precautions.
20. A nurse is planning to administer immunizations to a 2-month-old infant. Which of the
following actions should the nurse take to decrease the infant's pain?
A. Ask the parent to leave the room during the injections.
B. Administer the injections in the deltoid muscle.
C. Apply a warm pack to the injection site before administration.
D. Administer the injections while the infant is breastfeeding.
Answer: D. Administer the injections while the infant is breastfeeding.
21. A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which of
the following findings should the nurse expect?
A. Hypertension.
B. Increased urine output
C. Increased respiratory rate
D. Capillary refill of 2 seconds
Answer: C. Increased respiratory rate
22. A nurse at an inpatient facility is planning care for a child with an autism spectrum
disorder. Which of the following interventions should the nurse include in the plan of care?
A. Place the child in a semi-private room.
B. Vary daily routes when providing care for the child
C. Keep staff with the child brief
D. Keep the television on in the child's room for background noise.
Answer: C. Keep staff with the child brief
23. A nurse evaluates a 4-years child who has cystic fibrosis and has been receiving chest
physiotherapy treatments. The nurse should identify which of the following findings is an
indication that the therapy has been effective?
A. Increased urine output
B. Reduced pain
C. Increased expectoration
D. Increased heart rate.
Answer: C. Increased expectoration
24. A nurse is preparing to administer immunization to a 3-month-old infant. Which of the
following is an appropriate action for the nurse to take to deliver atraumatic care?
A. Provide a pacifier coated with an oral sucrose solution prior to the injections.
B. Inject the immunizations into the deltoid muscle
C. Apply an eutectic mixture of local anesthetics (EMLA) cream immediately before the
injections. - no, 60 minutes beforehand
D. Use a 20-gauge needle for the injections. - no, use a 22-25gauge needle, 1/2"-1" long
Provide a pacifier coated with an oral sucrose solution prior to the injections.
Answer: A. Provide a pacifier coated with an oral sucrose solution prior to the injections.
25. A nurse in an emergency department is caring for a child who experienced a submersion
injury. Which of the following is the priority action for the nurse to take?
A. Obtain ABG samples
B. Assist with intubation
C. Apply warming blankets
D. Administer an IV bolus.
Answer: B. Assist with intubation
26. A nurse in an emergency department is assessing an adolescent who reports inhalation of
gasoline. Which of the following findings should the nurse expect?
A. Hypothermia
B. Hyperactive reflexes
C. Ataxia - impaired balance or coordination
D. Pinpoint pupils.
Answer: C. Ataxia - impaired balance or coordination
27. A nurse provides teaching to the parents of a child who has varicella about the
management of the disease. Which of the following instructions should the nurse include in
the teaching?
A. Avoid bathing the child while vesicles are present.
B. Keep the child away from others until the skin is clear of scabs
C. Dress the child in warm clothing to promote the healing of vesicles.
D. Apply calamine lotion to vesicles on the child's skin.
Answer: B. Keep the child away from others until the skin is clear of scabs
28. A nurse reviews the medication records of a 15-month-old child who is scheduled to
receive the measles, mumps, and rubella (MMR) vaccines. Which of the following findings
should the nurse identify as a contraindication for receiving this vaccine?
A. Temperature of 37.2 C (99 E) degrees
B. Family history of seizures.
C. Upper respiratory infection 2 days ago
D. Allergy to neomycin
Answer: D. Allergy to neomycin.
29. A nurse is providing teaching to the parent of a child who has impetigo. Which of the
following instructions should the nurse include in the teaching?
A. Administer acyclovir PO two times per day
B. Soak hairbrushes in boiling water for 10 mins
C. Apply bactericidal ointment to lesions.
D. Seal soft toys in plastic bags for 14 days.
Answer: C. Apply bactericidal ointment to lesions.
30. A nurse is planning to admit a preschooler from the PACU following the removal of a
Wilms tumor. Which of the following children should the nurse identify as an appropriate
roommate for the preschooler?
A. A child who has cellulitis of the right radius.
B. A child who has impetigo
C. A child who has pneumonia
D. A child who has a fractured left femur.
Answer: D. A child who has a fractured left femur.
31. A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of
the following actions should the nurse take?
A. Apply warm compresses to the affected areas
B. Administer furosemide IV twice per day
C. Initiate contact precautions
D. Decrease the child's fluid intake.
Answer: A. Apply warm compresses to the affected areas
32. A nurse is creating a care plan for a toddler who is recovering following a routine surgical
procedure. Which of the following interventions should the nurse include?
A. Administer IV dantrolene sodium to the toddler.
B. Encourage the toddler to use an incentive spirometer
C. Place a cooling blanket on the toddler
D. Administer aspirin to the toddler as needed for pain. - can cause Reye's syndrome
Answer: B. Encourage the toddler to use an incentive spirometer
33. A nurse is caring for a preschooler who has a brain tumor. Which of the following
findings is the priority for the nurse to report to the provider?
A. Nightmares
B. Hyperactivity
C. Pruritus
D. Diplopia - double vision
Answer: D. Diplopia - double vision
34. A nurse is preparing to perform venipuncture to collect a blood sample from an infant.
Which of the following restraints should the nurse plan to use for this procedure?
A. Elbow
B. Jacket
C. Mitten
D. Mummy.
Answer: D. Mummy.
35. A nurse is caring for an infant who has a patent ductus arteriosus. The nurse should
identify that the defect is at which of the following locations of the heart? (you will find hot
spots to select in the artwork below. Select only the hot spot that corresponds to your
answer.)
Answer: The defect, patent ductus arteriosus (PDA), is located at the connection between the
aorta and the pulmonary artery, which in this image corresponds to the spot marked with a
circle and labeled "B".
36. A nurse provides teaching to the parents of a school-age child newly diagnosed with a
seizure disorder. The nurse should teach the parents to take the following actions during a
seizure?
A. Place the child in a prone position
B. Insert a tongue blade between the teeth.
C. Minimize movement of the limbs
D. Clear the area of hard objects.
Answer: D. Clear the area of hard objects.
37 A nurse is caring for a 3-year-old child who is recovering from surgery. Which of the
following methods should the nurse use to assess the child's pain level?
A. Oucher scale
B. Visual analog scale
C. Poker chip tool
D. Word graphic rating scale Oucher scale
Answer: A. Oucher scale
38. A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of
the following actions should the nurse take?
A. Apply a warm compress to the affected areas
B. Administer furosemide IV twice per day
C. Initiate contact precautions
D. Decrease the child's fluid intake
Answer: A. Apply a warm compress to the affected areas
39. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the
following immunizations should the nurse include in the plan?
A. Respiratory syncytial virus (RSV)
B. Pneumococcal conjugate (PCV)
C. Measles, mumps, and rubella (MMR)
D. Rotavirus
Answer: B. Pneumococcal conjugate (PCV)
40. A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin.
Which of the following laboratory values should the nurse report to the provider?
A. Creatinine 1.4mg/dL
B. BUN 6mg/dL
C. Creatinine 0.3 mg/dL
D. BUN 12mg/dL
Answer: A. Creatinine 1.4mg/dL
41. A nurse is caring for a school-age child who is 1hr postoperative following a
tonsillectomy. Which of the following actions should the nurse take? (Select all that apply)
A. Maintain the child in a supine position.
B. Provide cranberry juice to the child.
C. Discourage the child from coughing.
D. Observe the child for frequent swallowing.
E. Administer an analgesic to the child on a scheduled basis.
Answer: C. Discourage the child from coughing.
D. Observe the child for frequent swallowing.
E. Administer an analgesic to the child on a scheduled basis.
42. A nurse is caring for a group of clients. Which of the following findings should the nurse
report to the provider?
A. 3-month-old infant who has a respiratory rate of 30/min (25-30 normal)
B. An 18-month-old toddler who has a heart rate of 68/min
C. A school-age child who has a rectal body temperature of 37.3 C(99.1 F)
D. An adolescent who has a BP of 132/82 mm Hg
Answer: D. An adolescent who has a BP of 132/82 mm Hg
43. A nurse is caring for a 2-month-old infant with heart failure and receiving furosemide.
Which of the following findings is the nurse's priority?
A. Heart rate 162/min
B. Potassium 5.1 mEQ/L
C. Sunken anterior fontanel - sign of dehydration
D. Negative doll's eye reflex
Answer: C. Sunken anterior fontanel - sign of dehydration
44. A nurse in a family practice clinic is assessing a preschool-age child who recently
experienced the death of a sibling. Which of the following reactions is an age-appropriate
response to death?
A. The child feels responsible for the sibling's death
B. The child views the sibling's death as permanent
C. The child is curious about what happened to the sibling's body.
D. The child can give a logical explanation for the sibling's death
Answer: D. The child feels responsible for the sibling's death
45. A nurse in a community clinic is reviewing the laboratory results of four clients. The
nurse should identify which of the following sexuality transmitted infections is nationality
notifiable?
A. Bacterial vaginosis trichomoniasis
B. Genital herpes simplex virus
C. Human papillomavirus
D. Gonorrhea (CDC)
Answer: D. Gonorrhea (CDC)
46. A nurse is assessing a 24-month-old toddler. Which of the following findings should the
nurse rapport with the provider?
A. Has a vocabulary of 30 words
B. Holds his breath when having a temper tantrum
C. Eats a large amount of food one day, then very little the next
D. Steps 11 to 12 hr per day.
Answer: A. Has a vocabulary of 30 words (normal = 50-300 words)
47. A nurse is caring for a child in the PACU following a tonsillectomy. Which of the
following findings requires immediate interventions by the nurse?
A. The Faces scale Frequent swallowing
B. Dark brown blood noted in emesis
C. Axillary temperature 38C( 100 F)
D. Child reports a pain level of 5 on the FACES scale
Answer: A. The Faces scale Frequent swallowing
48. A nurse is providing teaching to the guardians of an infant who requires a Pavlik harness.
Which of the following instructions should the nurse include?
A. Apply baby powder under the harness straps daily
B. Massage lotion into the skin under the harness twice per day
C. Adjust the harness straps daily
D. Place the diaper under the straps of the harness.
Answer: D. Place the diaper under the straps of the harness.
49. A nurse is planning care for a child who is experiencing a sickle cell crisis. Which of the
following interventions should the nurse include in the plan of care?
A. Apply a cold compress to affected joints
B. Limit fruit intake
C. Administer meperidine as needed for pain
D. Initiate bed rest
Answer: D. Initiate bed rest
50. A nurse is prioritizing care for four clients. Which of the following clients should the
nurse assess first?
A. An adolescent who has sickle cell anemia and slurred speech
B. A toddler who has a partial-thickness burn on his right hand and requires a dressing
change
C. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of
nafcillin
D. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
Answer: A. An adolescent who has sickle cell anemia and slurred speech
51. A nurse is teaching a parent of a toddler about administering digoxin. Which of the
following statements by the parent indicates an understanding of the teaching?
A. I should give the medication with 4 ounces of my child's favourite juice
B. I should give my child water after giving the medication
C. I should give the medication with foods that are high in fiber
D. I should give my child another dose if he vomits right after taking the medication
Answer: B. I should give my child water after giving the medication
52. A nurse is assessing an adolescent client who has Hodgkin's lymphoma. Which of the
following findings should the nurse expect?
A. Flushed skin
B. Night sweats
C. Unexplained weight gain
D. Decreased body temperature.
Answer: B. Night sweats
53. A nurse teaches a parent about home interventions for a preschooler who is experiencing
night terrors. Which of the following instructions should the nurse include in the teaching?
A. Wait until the child indicates that he is tired before putting him to bed
B. Allow your child to watch an animated movie right before bedtime
C. Avoid allowing your child to sleep in your bed
D. Wake your child up during the night terror
Answer: C. Avoid allowing your child to sleep in your bed
54. A nurse is providing teaching to a parent of a child who has HIV. Which of the following
statements by the parent indicates an understanding of the teaching?
A. My child will need to double his medications for the next 6 months
B. My child will need to repeat his childhood immunizations once he is in remission
C. The risk of transmission decreases once my child is on zidovudine for 2 weeks
D. I will ensure that my child is tested for tuberculosis every year
Answer: D. I will ensure that my child is tested for tuberculosis every year
55. A nurse is preparing to apply lidocaine and prilocaine cream to a child before inserting an
IV catheter. Which of the following actions should the nurse plan to care for?
A. Gently rub the cream into the skin
B. Apply the cream 1 hr before the procedure
C. Wash the site with alcohol before applying the cream
D. Avoid removing the cream before the procedure
Answer: B. Apply the cream 1 hr before the procedure
56. A nurse is caring for a child who received partial-thickness burns to over 50% of his body
10 days ago and has splints over his joints to prevent contraction. Which of the following
actions should the nurse take? (Select all that apply)
A. Monitor intake and output
B. Provide a high-calorie client
C. Administer analgesics IM
D. Change dressing using an aseptic technique
E. Remove splints during sleep Monitor intake and output
Answer: B. Provide a high-calorie client
D. Change dressing using an aseptic technique
57. A nurse is preparing a child for a lumbar puncture. In which of the following positions
should the child be placed for the procedure?
A. Prone
B. Lateral
C. Semi-Fowler's
D. Supine
Answer: B. Lateral
58. A nurse is teaching a group of male adolescents about testicular self examination. Which
of the following statements should the nurse include in the teaching?
A. You should perform the examination once every other month - should be every month
B. You should notify your provider if your testes are firm and egg-shaped
C. perform the exam following a warm shower
D. If you feel a hard lump, wait 1 month and retest yourself
Answer: C. perform the exam following a warm shower
59. A nurse is creating a plan of care for an adolescent who has muscular dystrophy. Which
of the following interventions should the nurse include in the plan?
A. Avoid influenza and pneumococcal vaccines for 24 months
B. Initiate a referral for chest physiotherapy every 4 hr
C. Recommend the adolescent use a wheelchair to prevent stress on the lower extremities
D. Encourage the adolescent to perform incentive spirometry to maintain lung capacity.
Answer: D. Encourage the adolescent to perform incentive spirometry to maintain lung
capacity.
60. A nurse is caring for an adolescent who has a major depressive disorder. Which of the
following actions should the nurse take first?
A. Ask the client if he is considering harming himself
B. Administer an antidepressant to the client
C. Encourage the client to attend a group therapy session
D. Assist the client in completing his ADLs
Answer: A. Ask the client if he is considering harming himself
61. A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the
following findings is the nurse's priority?
A. Glycosuria
B. Cholesterol 189 mg/dL
C. Pre-prandial blood glucose 124 mg/dL
D. HbA1c 11.5%
Answer: D. HbA1c 11.5%
62. A nurse is planning to perform tracheostomy care for a toddler. Which of the following is
an appropriate action for the nurse to take?
A. Have the child flex his head when securing the ties.
B. Clean around the stoma with full-strength hydrogen peroxide
C. Use clean techniques to change the tracheostomy tube
D. Place the child in Trendelenburg position when performing care.
Answer: A. Have the child flex his head when securing the ties.
63. A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning.
Which of the following information should the nurse include in the teaching?
A. Limit foods high in iron
B. Avoid foods containing milk products
C. Use aspartame as a sugar substitute
D. Increase the toddler's protein consumption
Answer: B. Avoid foods containing milk products
64. A nurse is assessing a 6-month-old infant who has a respiratory syncytial virus. The nurse
should immediately report which of the following findings to the provider?
A. Tachypnea
B. Coughing
C. Brisk capillary refill
D. Pharyngitis
Answer: A. Tachypnea
65. A nurse reviews the complete blood count results for a child who is receiving treatment
for acute lymphoblastic leukemia. Which of the following findings should indicate to the
nurse that the treatment is having a therapeutic effect?
A. Hemoglobin 6.8g/dL
B. RBC count 5 mm3
C. WBC count 15000 mm3
D. Platelet count 34000 mm3 (150,000-400,000)
Answer: B. RBC count 5 mm3 (normal range)
66. A nurse is assessing a child who has heart failure. Which of the following findings is a
clinical manifestation associated with this diagnosis?
A. Bradycardia
B. Tachypnea
C. Tremors
D. Increased appetite
Answer: B. Tachypnea
67. A nurse is teaching a group of parents about childhood immunization. The nurse should
identify that infants should receive the first dose of the following immunizations at 12 months
of age.
A. Human papillomavirus
B. Inactivated poliovirus
C. Varicella
D. Hepatitis B.
Answer: C. Varicella
68. A nurse is reviewing the medical record of a 24-month-old child who has acute
lymphocytic leukemia. Which of the following actions should the nurse take?
A. Obtain rectal temperature every 4 hour
B. Place the child in a knee-chest position
C. Apply viscous lidocaine to the oral mucosa
D. Initiate bleeding precautions
Answer: D. Initiate bleeding precautions
69. A nurse is assessing a toddler who is 8 hr postoperative following a cardiac
catheterization procedure. Which of the following findings should the nurse report to the
provider?
A. Serum glucose 90 mg/dL
B. Blood pressure 102/58 mmHg
C. Weak pedal pulse distal to the site
D. Bilateral cool extremities
Answer: D. Bilateral cool extremities
70. A nurse is communicating with a child who has hearing loss. Which of the following
actions should the nurse take?
A. Maintain a neutral facial expression when speaking to the child
B. Change positions frequently to maintain the child's attention
C. Exaggerate the pronunciation of words
D. Use a light touch when initiating conversation
Answer: C. Exaggerate the pronunciation of words
71. A nurse is teaching a parent of a 10- month-old infant about home safety. Which of the
following instructions should the nurse include in the teaching? SATA
A. Ensure the crib mattress is in the lowest position
B. Select a toy chest that has a heavy, hinged lid
C. Keep toilet lids in the upright position
D. Remove labels forms containers that contain toxic substances
E. Place gates at the top and bottom of the stairs Ensure the crib mattress is in the lowest
position
Answer: A. Ensure the crib mattress is in the lowest position
E. Place gates at the top and bottom of the stairs
72. A nurse is assessing a school-age child who has heart failure and is taking furosemide.
Which of the following findings should the nurse identify as an indication that the medication
is effective?
A. An increase in venous pressure
B. a decrease in peripheral edema
C. a decrease in cardiac output
D. an increase in potassium levels
Answer: B. a decrease in peripheral edema
73. A nurse is assessing an infant who has acute otitis media. Which of the following findings
should the nurse expect (select all that apply)
A. Increased appetite
B. enlarged subclavian lymph node
C. Crying
D. Restlessness
E. fever
Answer: B. Crying
C. Restlessness
E. fever
74. A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine
iontophoresis Testing for Cystic Fibrosis. Which of the following statements should the nurse
include in the teaching?
A. We will measure the amount of protein in your baby's urine over 24 hour period
B. The test will measure the amount of water in your baby's sweat
C. a nurse will insert an IV prior to the test
D. your baby will need to fast for 8 hours prior to the test
Answer: B. The test will measure the amount of water in your baby's sweat
75. A nurse in an urgent care clinic is prioritizing care for children. Which of the following
children should the nurse assess first?
A. A toddler who has nephrotic syndrome and facial edema
B. a preschool-age child who has a muffled voice and no spontaneous cough
C. a preschool-age child who has diabetes mellitus and a blood glucose of 200 mg/dL
D. an adolescent who has Crohn's disease and recent weight loss of 5kg mg (11 lb)
Answer: B. a preschool-age child who has a muffled voice and no spontaneous cough
76. A nurse is providing teaching to the parents of a toddler who is to undergo a sweat
chloride test. Which of the following statements should the nurse include?
A. The purpose of the test is to determine if your child has Crohn's disease
B. the technician will use a device to produce an electrical current during the test
C. during the test, your child will be in a room that is cold
D. your child's sweat will be collected over 24 hours
Answer: D. your child's sweat will be collected over 24 hours
77. A nurse in the emergency department is caring for an adolescent who is requesting testing
for STI. Which of the following action is appropriate for the nurse to take?
A. Request verbal consent from the social worker
B. contact the client's parents to obtain phone consent
C. postpone the testing until the client's parents are present
D. obtain written consent from the client
Answer: D. obtain written consent from the client
78. A nurse in the emergency department is assessing the toddler who has hyperpyrexia
severe dyspnea and drooling which of the following actions should the nurse take first?
A. obtain a blood culture from the toddler
B. administering antibiotics to the toddler
C. insert an IV catheter for the toddler
D. prepare the toddler for nasotracheal intubation
Answer: D. prepare the toddler for nasotracheal intubation
79. A nurse is providing teaching to a 10-year-old child scheduled for arterial cardiac
catheterization. Which of the following information should the nurse include in the teaching?
A. You will have your dressing removed 12 hours after the procedure
B. you will need to keep your legs straight for 8 hours following the procedure
C. you will be on a clear liquid diet for 24 hours following the procedure
D. you will be on bed rest for 2 days after the procedure
Answer: B. you will need to keep your legs straight for 8 hours following the procedure
80. A nurse is caring for a preschooler who is post-operative following a tonsillectomy. The
child is now ready to resume oral intake which of the following dietary choices should the
nurse offer the child?
A. sugar-free Cherry gelatin
B. vanilla ice cream
C. chocolate milk
D. lime flavored ice pop
Answer: D. lime flavored ice pop
81. A nurse is caring for a 10 month old child was brought to the emergency department by
his parents following a head injury. Which of the following actions should the nurse take
first?
Inspect for fluid leaking from the ears (thinking about CSF leakage severe trauma = urgent,
after respiratory status is confirmed)
A. assess respiratory status
B. check pupil reactions
C. examine the scalp for lacerations
Answer: B. assess respiratory status
82. A charge nurse is planning care for an infant who has failure to thrive. Which of the
following actions should the nurse include in the plan of care?
A. Assign consistent nursing Staff Care for the infant
B. Keep infant in a visually stimulating environment
C. use half-strength formula when feeding the infant
D. give the infant fruit juice between feedings
Answer: B. Keep infant in a visually stimulating environment
83. A nurse is providing teaching about home care to the parent of a child who has scabies.
Which of the following instruction should the nurse include in the teaching?
A. Wash your clients hair with shampoo containing Ketoconazole
B. soak Combs and brushes in boiling water for 10 minutes
C. apply petroleum jelly to the affected areas
D. treat everyone who came into close contact with a child
Answer: D. treat everyone who came into close contact with a child
84. A nurse is caring for a preschooler who refuses to take a start dose of oral
diphenhydramine. Which of the following statements should the nurse make?
A. The medication isn't bad it taste like candy
B. let me know when you want to take the medication
C. the medication will treat your hypersensitivity reaction ( too much "Adult" terminology/
jargon for pre schooler to understand)
D. sometimes, when a child has to take medication, they feel sad.
Answer: D. sometimes, when a child has to take medication, they feel sad.
85. A nurse is teaching the parent of a school-age child about bicycle safety. Which of the
following instructions should the nurse include in the teaching?
A. Your child should walk the bicycle through intersections
B. your child's feet should be three to six inches off the ground when Seated on the bicycle
C. you should try to keep the bicycle at least three feet from the curb while riding in the street
D. your child should ride the bicycle against the flow of traffic
Answer: A. Your child should walk the bicycle through intersections
86. A nurse is caring for a school-age child following the application of a cast to a Fractured
right tibia. Which of the following actions should the nurse take first?
A. Teach the child about cast care
B. Pad the edges of the cast
C. administer pain medication
D. Elevate the child's leg
Answer: D. Elevate the child's leg (elevate the child cast above the heart during the first 2448 hrs)
87. A nurse is preparing to collect a urine specimen from a female infant using a urine
collection bag. Which of the following actions should the nurse take?
A. Apply lidocaine gel to the perineum before attaching the bag
B. Position the opening of the bag over the urethra and the anus
C. Stretch the perineum taught when applying the bag
D. Place a snuff fitting diaper over the drainage bag
Answer: C. Stretch the perineum taught when applying the bag
88. A nurse is planning care for a toddler who has developed oral ulcers in response to
chemotherapy. Which of the following actions should the nurse include in the plan of care?
A. Schedule routine Oral Care every 8 hours
B. Cleanse the gums with saline soaked gauze
C. more sending me closer with lemon glycerin swabs- causes tooth decay and erosion of
tissue
D. administer oral viscous lidocaine - risk of aspiration
Answer: A. Schedule routine Oral Care every 8 hours
89. A nurse is providing discharge teaching to the parents of an infant who is at risk for
sudden infant death syndrome (SIDS). Which of the following statements by the parent
indicates an understanding of the teaching?
A. I will have my baby sleep next to me in the bed during the night
B. Elmo my baby stuffed animal to the corner of her crib while she sleeps
C. I will dress my baby in lightweight clothing to sleep
D. I will lay my baby on her side to sleep for her naps
Answer: C. I will dress my baby in lightweight clothing to sleep
90. A nurse is monitoring an infant who is receiving opioids for pain. Which of the following
findings should indicate to the nurse that the medication is having a therapeutic effect?
A. Increased blood pressure
B. Limb withdrawal
C. relaxed facial expression
D. bradycardia
Answer: C. relaxed facial expression
91. A nurse is caring for a three-month-old infant who has cleft of the soft palate. Which of
the following actions should the nurse take?
A. discontinue feeding if the client's eyes become watery
B. postpone burping the infant until after completing each feeding
C. Elevate the infant's head to a 10-degree angle during feedings
D. Feed the infant 177.4 ml (6 oz) of Formula 3 times a day
Answer: A. discontinue feeding if the client's eyes become watery
92. A nurse is caring for a child who has hyponatremia. Which of the following findings
should the nurse expect?
A. Tetany
B. weight gain
C. Elevated heart rate
D. excessive diaphoresis Tetany
Answer: A. Tetany
93. A nurse is preparing to administer an enteral feeding to an adolescent who has an NG
tube. Which of the following actions should the nurse take first?
A. Set the administration rate on the feeding pump
B. flush the tube with water
C. check the pH of the gastric secretion
D. attach the feeding bag tubing to the end of the NG Tube
Answer: C. check the pH of the gastric secretion
94. A nurse is caring for an adolescent who is 1 hour post-operative following an
appendectomy. Which of the following findings should the nurse report to the provider?
A. Heart rate 63/minute
B. muscle rigidity
C. temperature 36.4 Celsius (97.5 Fahrenheit)
D. abdominal pain
Answer: D. abdominal pain
95. A nurse in a provider's office is preparing to administer immunization to a 12 year old
client during a well-child visit. Which of the following immunization should the nurse plan to
administer? SATA
A. Diptheria, tetanus and pertussis (D-Tap)
B. human papillomavirus (HPV)
C. Varicella
D. hepatitis A
Answer: A. Diptheria, tetanus and pertussis (D-Tap)
B. human papillomavirus (HPV)
96. Nurse is planning care for an 8 month old infant who has heart failure. Which of the
following actions should the nurse include in the plan of care?
A. Repeat digoxin dosage is the infant vomit within 1 hour of administration
B. Place infant in a prone position
C. administer cool, humidified oxygen via nasal cannula
D. provide less frequent, higher volume feeding
Answer: D. provide less frequent, higher volume feeding
97. A nurse is planning care for a school-age child who is admitted from the emergency
department 12 hours ago. Which of the following interventions should the nurse include to
promote adequate sleep for the child?
A. Provide the child with video games prior to bedtime to reduce stress
B. allow the child to adjust their bedtime to promote autonomy
C. leave the lights on in the child's room to promote safety
D. follow the child home sleep routine to reduce anxiety
Answer: D. follow the child home sleep routine to reduce anxiety
98. A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month old
infant. Which of the following actions should the nurse plan to take?
A. cover the insertion site with an opaque dressing
B. use a 24 gauge catheter to start the IV
C. start the IV on the infant's foot
D. change the IV site every 3 days
Answer: B. use a 24 gauge catheter to start the IV
99. A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a
new prescription for digoxin. Which of the following manifestations should the nurse include
as an indication of digoxin toxicity?
A. Diaphoresis
B. Polyuria
C. Bradycardia
D. jaundice
Answer: C. Bradycardia
100. A nurse is reviewing the laboratory results of a child was recently admitted or suspected
rheumatic fever. The nurse should identify that which of the following laboratory tests can
contribute to confirm this diagnosis select all that apply.
A. partial thromboplastin time (PTT)
B. erythrocyte sedimentation rate (ESR)
C. blood urea nitrogen (BUN)
D. C-reactive protein (CRP)
E. anti streptolysin O (ASO) titer
Answer: B. erythrocyte sedimentation rate (ESR)
D. C-reactive protein (CRP)
E. anti streptolysin O (ASO) titer
101. A nurse is caring for an infant who receives intermittent enteral feeding through a
gastrostomy tube. Which of the following actions should the nurse take when administering a
feeding? Select all that apply
A. offer the infant a pacifier during readings
B. formula to 39° C (102 degrees Fahrenheit ) prior to Administration
C. check the for residual volume by aspirating stomach contents
D. instill the formula over a period of 30 and 45 minutes offer the infant a pacifier during
readings
Answer: C. check the for residual volume by aspirating stomach contents
D. instill the formula over a period Of 30 and 45 minutes
102. A nurse is planning care for a child who has osteomyelitis. Which of the following
interventions should the nurse include in the plan of care?
A. Encourage frequent physical activity to increase bone mass
B. maintain patent intravenous catheter
C. initiate contact precaution for the child
D. provide a high calorie low protein diet
Answer: B. maintain patent intravenous catheter
103. A nurse is providing teaching to the guardian of a school-age child who has sickle cell
disease about management of the illness. Which of the following instructions should the
nurse include?
A. Apply cold compress to painful areas
B. I shall wear a surgical mask to school
C. encourage physical activity as tolerated
D. offer fluids of bedtime
Answer: B. I shall wear a surgical mask to school
104. A nurse is assessing a 5 month old infant. Which of the following findings should the
nurse report to the provider?
A. Unable to hold a bottle
B. exhibits head lag when pulled a sitting position
C. absent grasp reflex
D. unable to roll from back to abdomen
Answer: B. exhibits head lag when pulled a sitting position
105. A nurse is caring for a five-year-old child following a tonsillectomy and adenoidectomy.
Which of the following findings should the nurse identify as an indication of hemorrhage?
A. Flushing of the face
B. continuous swallowing
C. blood pressure 99/ 56 mmhg
D. heart rate 54/ minutes
Answer: B. continuous swallowing
106. A nurse is discussing coping mechanisms with a parent of a three-month-old infant
which of the following therapeutic questions should the nurse ask the parent?
A. What do you do when your infant is fussy?
B. Are you willing to take new parenting classes?
C. Does parenting cause you stress?
D. Is it overwhelming when your infant is having a bad day?
Answer: A. What do you do when your infant is fussy?
107. A nurse is providing teaching about the effects of sun exposure to a parent of a toddler
which of the following responses by the parent indicates an understanding of the teaching?
A. my child should wear a wide-brimmed hat
B. my child should remain under a beach umbrella during morning hours
C. I should apply 10 SPF sunscreen to my child's entire body
D. I should dress my child in loose active clothing
Answer: C. I should apply 10 SPF sunscreen to my child's entire body
108. A nurse is evaluating a 6 year old child who has cystic fibrosis and has been receiving
chest physiotherapy treatment. The nurse should identify which of the following findings as
an indication of the therapy has been effective?
A. Increased urine output
B. increase expectoration
C. reduced pain
D. increased heart rate
Answer: D. increase expectoration
109. A nurse is planning care for a six-month-old infant who has bacterial meningitis. Which
of the following interventions should the nurse include in the plan of care?
A. Place the infant in a semi-private room
B. keep the television on in the room to provide background noise
C. Pad the side rails of the crib
D. provide for you can range of motion to the neck and shoulders
Answer: C. Pad the side rails of the crib (seizure precautions)
110. A nurse is reviewing the medical record of a child with cystic fibrosis which of the
following should the nurse report to the provider? Click on the exhibit button for additional
information about the client.
A. heart rate
B. HbA1c
C. oxygen saturation
D. WBC
Answer: B. HbA1c
111. A nurse is assessing an infant who has severe dehydration due to gastroenteritis which of
the following findings should the nurse expect?
A. Increased respiratory rate
B. capillary refill of 2 seconds
C. Hypertension
D. increased urine output
Answer: A. Increased respiratory rate
112. A nurse is assessing an infant who has intussusception. Which of the following findings
should the nurse expect?
A. sausage-shaped abdominal Mass
B. board like abdomen
C. Constipation
D. increased urinary output
Answer: A. sausage-shaped abdominal Mass
113. A nurse is caring for a 14 year old adolescent who has a cast on the right arm and
swelling of their right hand. The nurse elevates The adolescent's affected extremity. The
nurse should identify which of the following findings is an indication that the intervention has
been effective?
A. The Adolescent reports of the cast feels tight
B. The Adolescents hands feel cool to touch
C. the Adolescent is able to move their fingers freely
D. the Adolescent reports feeling tingling in their arms
Answer: C. the Adolescent is able to move their fingers freely
114. A nurse in a provider's office is assessing the vital signs of a two-year-old child at a
well- child visit. Which of the following findings should the nurse report to the provider?
A. Respiratory rate 26/min
B. pulse rate 98/minutes
C. temperature 37.2 Celsius (99 Fahrenheit)
D. blood pressure 118/74 mmhg
Answer: D. blood pressure 118/74 mmhg
115. A nurse is preparing to administer a prescribed medication to a toddler whose parent is
nearby. Which of the following actions should the nurse take to identify the toddler?
A. check the toddler's room number against their ID band
B. check the toddler's ID band against the medical record
C. ask the parent to confirm the toddler's identity
D. ask another nurse to confirm to toddlers identity
Answer: B. check the toddler's ID band against the medical record
116. A nurse is teaching home care to the parents of a preschool-age child who has heart
failure. Which of the following information should the nurse include in the teaching?
A. weight the child once each month month
B. withhold digoxin of the child's pulse is greater than 100/minutes
C. provide for periods of rest
D. increase the child's oxygen flow rate until the child no longer has cyanosis
Answer: C. provide for periods of rest
117. A nurse in the PACU is caring for a school-age child immediately following a
tonsillectomy. Which of the following actions should the nurse take?
A. Place the child in a side-lying position
B. offer the child ice cream when alert
C. instruct a child to drink fluids through a straw
D. encourage the child to deep breathe and cough
Answer: A. Place the child in a side-lying position
118. A nurse is reviewing the medical record of a 15 month old child who is scheduled to
receive measles, mumps, rubella1. Which of the following findings Should the nurse identify
as a contradiction for receiving the vaccine?
A. Allergy to neomycin
B. upper respiratory infection 2 days ago
C. temperature of 37.2 (99 Fahrenheit)
D. family history of seizures
Answer: A. Allergy to neomycin
119. A nurse is assessing a school-age child cranial nerve function. Which of the following
actions should the nurse ask the child to take when assessing the accessory nerve?
A. Move their tongue in all directions
B. follow a light in the six cardinal position
C. shrug their shoulders against mild pressure
D. show their teeth while smiling
Answer: C. shrug their shoulders against mild pressure
120. A nurse is performing a cranial nerve assessment on a school-age child. Which of the
following findings indicates proper function of the child trigeminal nerve?
A. The child montanes balance when standing with eyes closed
B. the child correctly identify specific scent
C. the child has asymmetrical jaw strength when Biting Down
D. the child exhibits a gag reflex when stimulated with a tongue blade
Answer: C. the child has asymmetrical jaw strength when Biting Down
121. A nurse is providing support to a family whose infant died from sudden infant death
syndrome (Sid's) which of the following actions should the nurse take?
A. Discourage the parents from allowing siblings to view the body
B. avoid discussing details of the attempt to revive the infant
C. provide a follow-up phone call one week following the infant's death
D. acknowledge the family members feelings of guilt
Answer: D. acknowledge the family members feelings of guilt
122. A nurse in the emergency department is caring for a child who has a temperature of 39.1
degrees C is (102.4 Fahrenheit) and suspect the diagnosis of bacterial meningitis. Which of
the following actions should the nurse take first?
A. prepare the child for a lumbar puncture
B. dim the lights in the child's room (SEIZURE PRECAUTION) (Other study guides say this
one)
C. administering an antipyretic to the child (this one too cause they have a high fever)
D. Implement droplet precautions for the child
Answer: D. Implement droplet precautions for the child (need to start isolation as soon as
meningitis is suspected)
123. A nurse is caring for an infant who has rotavirus. Which of the following findings
indicates that the infant is moderately dehydrated?
A. capillary refill 1 seconds
B. weight loss 7% lower
C. Respiratory rate 28/ minute
D. bradycardia
Answer: B. weight loss 7% lower
124. A nurse is providing teaching to the guardian of a school-age child who has seizure
disorder. Which of the following factors should the nurse include as a common trigger that
increases the risk of seizure?
A. Prolonged headache
B. decrease temperature
C. lack of sleep
D. exposure to second-hand smoke
Answer: C. lack of sleep
125. A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and
notes the clients potassium level is 3.2 meq L which of the following assessment findings
should the nurse expect?
A. Hypertension
B. Hyporeflexia
C. hyperactive bowel sounds
D. Oliguria
Answer: D. Oliguria
126. A nurse is planning care for an adolescent who has sickle cell anemia. Which of the
following immunizations should the nurse include in the plan?
A. Respiratory sync functional virus (RSV to call)
B. Rotavirus
C. measles, mumps, and rubella (MMR)
D. pneumococcal conjugate (pcv13)
Answer: D. pneumococcal conjugate (pcv13)
127. A nurse is planning care for a child who has varicella. Which of the following
interventions should the nurse plan to include?
A. Initiate Airborne precaution
B. assess the oral cavity for koplik spots
C. administer aspirin for fever
D. provide the child with a warm blanket
Answer: A. Initiate Airborne precaution
128. A nurse is planning care for a school-age child who has a new diagnosis of Legg calve
perthes disease. Which of the following interventions should the nurse include in the plan of
care?
A. instruct a child to perform weight bearing exercises
B. explain to the child that the disease will last 3 to 6 months
C. encourage the guardian to keep their child home from school for one month
D. administer ibuprofen to the child for discomfort
Answer: D. administer ibuprofen to the child for discomfort
129. A nurse is caring for a two-year-old child who has cystic fibrosis and is being
discharged from the hospital. The nurse should ensure that which of the following pieces of
equipment is available for the child's home?
A. steam vaporizer
B. suction machine
C. continuous positive airway pressure machine
D. high frequency chest compression vest
Answer: D. high frequency chest compression vest
130. A nurse is providing teaching for the parent of a child who has measles. Which of the
following information should the nurse include?
A. Bathe the child using tepid water
B. remove loose crust from the lesions
C. give the child aspirin for a fever
D. withhold live vaccines for 3 months Bathe the child using tepid water
Answer: A. Bathe the child using tepid water
131. A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings
should the nurse expect?
A. Steatorrhea
B. Rhinorrhea
C. weight gain
D. visible peristalsis
Answer: A. Steatorrhea
132. A nurse is planning to administer diphenhydramine 1.25 mg/kg IV to a school-age child
who weighs 55 lb. Available is diphenhydramine 50 mg/ml. How many ml should the nurse
administer. Round the answer to the nearest tenth. Use leading zero that applies. Do not use a
trailing zero.
Answer: 0.6 mL
133. A nurse is caring for a child during a tonic-clonic seizure. Which of the following
actions should the nurse take? SATA
A. Clear the area of hard objects
B. Firmly hold the child's arms to one side
C. Place a pillow under the childs head
D. Insert a tongue blade into the child's mouth
E. Loosen tight clothing around the childs neck
Answer: A. Clear the area of hard objects
C. Place a pillow under the childs head
E. Loosen tight clothing around the childs neck
134. A nurse is teaching a parent of a preschool age child about management of sleep terrors.
Which of the following instructions should the nurse include?
A. Take the child to the parents bed to resume sleep
B. Allow the child to fall asleep with the tv on
C. Remain uninvolved until the child awakens
D. Schedule professional counseling for the child
Answer: C. Remain uninvolved until the child awakens
135. A nurse is planning care for an 8month old infant who has bronchiolitis. Which of the
following actions should the nurse include in the plan of care?
A. Use a bulb syringe to suction the nares
B. Place the infant in a room with negative pressure airflow
C. Administer a meningococcal vaccine upon admission
D. Initiate IV antibiotic therapy
Answer: A. Use a bulb syringe to suction the nares
136. A nurse is preparing a parents education class about nutrition for toddlers. The nurse
should identify which of the following findings as an indication of protein deficiency?
A. Dry, Thinning Hair
B. Muscle Twitching
C. Dental Caries
D. Poor Skin Turgor
Answer: A. Dry, Thinning Hair
137. A nurse is assessing a preschool age child who has celiac disease. Which of the
following findings should the nurse expect?
A. Obesity
B. Polyphagia
C. Steatorrhea
D. Chronic Constipation
Answer: C. Steatorrhea
138. A nurse is reviewing the laboratory results of a preschool-age child who has hematuria.
Which of the following results should the nurse report to the provider?
A. Platelets: 170, 000
B. Hgb 12
C. Hematocrit 36
D. BUN 21
Answer: D. BUN 21
139. A nurse is admitting a school age child who has osteomyelitis. Which of the following
actions should the nurse take first?
A. Administer antibiotics
B. Teach the child nonpharmacological pain management techniques
C. Request a referral for PT
D. Obtain a blood culture
Answer: D. Obtain a blood culture
140. A nurse collects data from a toddler who weighs 20 kg (44 Lb) and has a full thickness
burn to 10% of his body. Which of the following findings should the nurse report to the
provider?
A. Respiratory rate 25/min
B. Bowel sodium 20/min
C. Urinary output 35/hr.
D. Increased restlessness
Answer: D. Increased restlessness
