NGN ATI RN PEDIATRICS PROCTORED EXAM 2023 / NEXT GEN ATI
PEDIATRICS PROCTORED EXAM 2023 70 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES |ALREADY GRADED
A+||BRAND NEW!!
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
A nurse is providing teaching to a 10 year old child with scheduled for an 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
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
A nurse is caring for an infant who has Patent ductus arteriosus. The nurse should identify that
the defect is a switch 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)
A. use half-strength formula when feeding the infant
B. give the infant fruit juice between feedings
Answer: A. use half-strength formula when feeding the infant
B. give the infant fruit juice between feedings
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
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 preschooler 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.
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'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
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
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: C. Crying
D. Restlessness
E. Fever
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
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
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 sweat will be collected over 24 hours
Answer: B. the technician will use a device to produce an electrical current during the test
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
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 antibiotic 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
A nurse is preparing a school-age child for an invasive procedure. Which of the following actions
should the nurse plan to take?
A. plan for 30 minute teaching session about the procedure
B. use vague language to describe the procedure
C. explain the procedure to the child when they are in the playroom
D. demonstrate deep breathing and Counting exercises
Answer: C. explain the procedure to the child when they are in the playroom
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: 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
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
D. administer oral viscous lidocaine
Answer: A. Schedule routine Oral Care every 8 hours
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
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
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
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
Answer: A. Tetany
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
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
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?
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)
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
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: B. allow the child to adjust their bedtime to promote autonomy
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
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
A nurse is reviewing the laboratory results of a child who was recently admitted or suspected
rheumatic fever. The nurse should identify which of the following laboratory tests can contribute
to confirm this diagnosis and 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
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 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: A. my child should wear a wide-brimmed hat
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: B. increase expectoration
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
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 (13.45%)
C. oxygen saturation
D. WBC
Answer: B. HbA1c (13.45%)
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
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
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 Adolescents affected extremity. The nurse should
identify that 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
A nurse in a provider's office is assessing the vital signs of a two-year-old child at a wellchild
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
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
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
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
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
A nurse is assessing a school-age child's cranial nerve function. Which of the following actions
should the nurse ask the child to take when assessing the accessory nerve?
A. show their teeth while smiling - VII the cranial nerve (Facial Nerve) assessment.
B. Follow a light in the six cardinal positions - VI th cranial nerve( Abducens).
C. Move their tongue in all directions- XII th cranial nerve (Hypoglossal) Assessment.
D. shrug their shoulders against mild pressure
Answer: D. shrug their shoulders against mild pressure
A nurse is performing a cranial nerve assessment on a school-age child. Which of the following
findings indicate 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
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
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? Tell me more
A. prepare the child for a lumbar puncture
B. dim the lights in the child's room (SEIZURE PRECAUTION)
C. administering an antipyretic to the child
D. Implement droplet precautions for the child
Answer: B. dim the lights in the child's room (SEIZURE PRECAUTION)
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
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
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 D intake once you start to menstruate
Answer: A. Increase the amount of your dietary iron intake
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
Answer: A. offer the infant a pacifier during readings
C. check the for residual volume by aspirating stomach contents
D. instill the formula over a period Of 30 and 45 minutes
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
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. but I shall wear a surgical mask to school
C. encourage physical activity as tolerated
D. offer fluids of bedtime
Answer: B. but I shall wear a surgical mask to school
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 (6 months)
B. exhibits head lag when pulled a sitting position
C. absent grasp reflex (3 months)
D. unable to roll from back to abdomen (6 months)
Answer: B. exhibits head lag when pulled a sitting position
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
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?
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: C. hyperactive bowel sounds
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)
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
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
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
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
Answer: D. withhold live vaccines for 3 months
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
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
EXTRA’s
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should
immediately report which of the following findings to the provider?
A. Tachypnea (rapid breathing)
B. Retractions (use of accessory muscles to breathe)
C. Low-grade fever
D. Decreased urine output
Answer: A. Tachypnea (rapid breathing)
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. Pinpoint pupils
B. Hypothermia
C. Ataxia
D. Hyperactive reflexes
Answer: C. Ataxia
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 contractures. Which of the following actions
should the nurse take? (SATA)
A. Provide a high-calorie diet
B. Change dressing using aseptic technique
C. Administer analgesics IM ?
D. Monitor intake and output
E. Remove splints during sleep
Answer: A. Provide a high-calorie diet
B. Change dressing using aseptic technique
D. Monitor intake and output
A nurse is reviewing the medical record of a 15-moth-old who is scheduled to receive the
measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse
identify as a contraindication for receiving this vaccine?
A. Temperature of 37.2 C (99 F)
B. Family history of seizures
C. Allergy to neomycin
D. Upper respiratory infection 2 days ago
Answer: C. Allergy to neomycin
A nurse is admitting a child who has acute epiglottitis. Which of the following actions should the
nurse take?
A. Check oxygen saturation every 4hr
B. Assist the child into supine position
C. Initiate droplet isolation precautions
D. Obtain a throat culture
Answer: C. Initiate droplet isolation precautions
A nurse is assessing a 24-month-old toddler, which of the following findings should the nurse
report to provider?
A. Sleeps 11 to 12 hr. per day
B. Eats large amounts of food one day then very little the next
C. Has a vocabulary of 30 words
D. Hold his breath when having a temper tantrum
Answer: C. Has a vocabulary of 30 words
A nurse is caring for a preschooler who has brain tumor (seizure risk) . Which of the following
findings is the priority for the nurse to the provider?
A. Hyperactivity
B. Pruritus
C. Diplopia- (visual disturbances headache, speech disturbances)
D. Nightmares
Answer: C. Diplopia- (visual disturbances headache, speech disturbances)
A nurse is teaching a group of parents about childhood immunizations. The nurse should identify
that infant should receive the first dose of which of the following immunization at 12 months of
age?
A. Inactivated polio virus
B. Varicella (live virus)
C. Human papillomavirus
D. Hepatitis B
Answer: B. Varicella (live virus)
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. Decreased body temperature
D. Unexplained weightz gain
Answer: B. Night sweats
A nurse is planning care for an adolescent who has sickle cell anaemia. Which of the following
immunizations should the nurse include in the plan?
A. Pneumococcal conjugate (PCV13)
B. Measles, mumps, and rubella (MMR)
C. Respiratory syncytial virus (RSV)
D. Rotavirus
Answer: A. Pneumococcal conjugate (PCV13)
A nurse is providing teaching to the guardians of an infant who requires a Pavlik harness.
Which of the following interventions should the nurse include?
A. Adjust the harness straps daily
B. "message lotion into the skin under the harness twice per day
C. "apply baby powder under the harness straps daily."
D. "place the diaper under the harness straps."
Answer: D. "place the diaper under the harness straps."
A nurse is teaching about growth and development to a parent of a 12-year-old child. The nurse
should instruct the parent to expect the child to exhibit which of the following characteristics
during early adolescence?
A. decelerating growth rate
B. increase self-esteem.
C. emotional separation from parent.
D. mood swing.
Answer: D. mood swing.
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a
seizures disorder. The nurse should teach the parent s to take which of the following actions
during a seizure?
A. Place the child in a prone position
B. Inset 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.
A nurse is caring for a group of clients. Which of the following findings should the nurse report
to the provider?
A. A school age child who has a rectal body temperature of 37.3 C (99.1 F)
B. An 18-month-old toddler who has a heart rate of 68/min
C. An adolescent who has a BP of 132/82 mm hg
D. A 3-month-old infant who has a respiratory rate of 36/min
Answer: B. An 18-month-old toddler who has a heart rate of 68/min
A nurse is educating an adolescent following this 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 arms
B. I should expect my fingers to be swollen for several days
C. I will elevate my broken arm on pillows a tonight
D. I will sprinkle baby powder into the cast if my arm itches
Answer: A. I should limit the use of the fingers of my broken arms
A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn
to 10% of this body. Which of the following findings should the nurse report to the provider?
A. Increased restlessness
B. Respiratory rate 25/min
C. Bowel sounds 20/min
D. Urinary output 35 mL/hr
Answer: A. Increased restlessness
A nurse is evaluating 4-year –old child who has cystic fibrosis and has been receiving chest
physiotherapy treatments the nurse should identify which of the following finding as an
indication that the therapy has been effective?
A. increase urine output
B. increase heart rate
C. increase expectoration
D. reduce pain.
Answer: C. increase expectoration
A nurse in a community clinic is reviewing the laboratory results of four clients. The nurse
should identify that which of the following sexually transmitted infections is nationally
notifiable?
A. Bacterial vaginosis trichomoniasis
B. Genital herpes simplex virus
C. Human papilloma virus
D. Gonorrhea - (Four STDs are nationally notifiable, chlamydia, gonorrhea, syphilis, and
chancroid, and state and local STD control programs provide CDC with case reports for these
conditions)
Answer: D. Gonorrhea - (Four STDs are nationally notifiable, chlamydia, gonorrhea, syphilis,
and chancroid, and state and local STD control programs provide CDC with case reports for
these conditions)
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an
IV catheter. Which of the following actions should the nurse plan to take?
A. Wash the site with alcohol prior to applying the cream
B. Gently rub the cream into the skin (never)
C. Apply the cream 1 hr. before the procedure (Leave the cream on for 30–60 minutes)
D. Avoid removing the cream prior to the procedure.
Answer: C. Apply the cream 1 hr. before the procedure (Leave the cream on for 30–60 minutes)
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 my child water after giving the medication
B. I should mix the medication with 4 ounces of my child’s favorite juice
C. I should give my child another dose if he vomits right after taking the medication
D. I should give the medication with foods that are high in fiber
Answer: A. I should give my child water after giving the medication
A nurse is preparing to administer immunizations 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 prior to injections
B. Inject the immunizations into the deltoid muscle
C. Use as 20-gauge needle for injections
D. Apply eutectic mixture of local anesthetics cream immediately before the injections
Answer: A. Provide a pacifier coated with an oral sucrose prior to injections
A nurse is preparing to administer ondansetron 0.15 mg/kg IV to child who is receiving
chemotherapy and weighs 29.4 kg. Available is ondansetron 4 mg/2 mL solution. How many mL
should the nurse administer? (Round the answer to the nearest tenth. Use a leading sero if it
applies. Do not use a trailing zero)
Answer: The nurse should administer 2.2 mL of the ondansetron solution.
A nurse is assessing a toddler who has a history of lead poisoning. Which of the following
actions should the nurse take?
A. Obtain a stool specimen for lead levels
B. Initiate a low-iron diet for lead absorption
C. Perform developmental testing for delays
D. Inspect the skin for discoloration
Answer: C. Perform developmental testing for delays
A nurse is caring for an adolescent who has major depressive disorder. Which of the following
actions should the nurse take first?
A. Administer an antidepressant to the client
B. Encourage the client to attend a group therapy session
C. Assist the client in completing his ADLs
D. Ask the client if he is considering harming himself
Answer: D. Ask the client if he is considering harming himself
A nurse in the emergency department is caring 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 methylprednisolone
B. Administer oxygen
C. Administer a nebulized bronchodilator
D. Administer epinephrine
Answer: D. Administer epinephrine
A school nurse is assessing a 7-year-old student. The nurse should identify which of the
following findings as a potential indicator of physical abuse?
A. Weight in 45th percentile
B. Bruising around the wrists
C. Abrasions on the knees
D. Front deciduous teeth missing
Answer: B. Bruising around the wrists
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. Seal soft toys in a plastic bag for 14 days
B. Soak hairbrushes in boiling water for 10 min
C. Administer acyclovir PO two times per day
D. Apply bactericidal ointment to lesions (Honey colored crusting)
Answer: D. Apply bactericidal ointment to lesions (Honey colored crusting)
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 is curious about what happened to the sibling’s body ?
B. The child feels responsible for the sibling’s death
C. The child can give a logical explanation for the sibling’s death
D. The child views the sibling’s death as permanent
Answer: B. The child feels responsible for the sibling’s death
A nurse is teaching the guardian of a 5-year-old child who has encopresis (bowel mishaps) about
management of the condition. Which of the following statements by the guardian indicates an
understanding of the teaching?
A. I will have my child try to defecate 15 minutes after each meal (bowel retraining)
B. I will increase my child’s fluid intake
C. I will have my child sit on the toilet for 30 minutes at a time
D. I will increase my child dairy intake
Answer: A. I will have my child try to defecate 15 minutes after each meal (bowel retraining)
A nurse is planning to admit a preschooler from the PACU following removal of a Wilms’ tumor
(adrenal gland tumor cancer) (never palpate). 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 a fractured left femur
C. A child who has viral pneumonia
D. A child who has impetigo
Answer: B. A child who has a fractured left femur
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 lie a nurse auscultate his lungs
B. An 8-month-old infant cries when his parents leave the room
C. A mother is hesitating to comfort her 6-month-old infant
D. A toddler has bruises on his knees
Answer: A. A toddler repeatedly refuses to lie a nurse auscultate his lungs
A nurse is planning to administer immunization to a 2-month-old infant. Which of the following
actions should the nurse take to decease the infant’s pain?
A. Apply a warm pack to the injection site prior to administration
B. Ask the parent to leave the room during the injections
C. Administer the injections in the deltoid muscle
D. Administer the injection while the infant is breastfeeding
Answer: D. Administer the injection while the infant is breastfeeding
A nurse is assessing a child who has heart failure. Which of the following findings is a clinical
manifestation associated with this diagnosis?
A. Tremors
B. Tachypnea
C. Increased appetite
D. Bradycardia
Answer: B. Tachypnea
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
B. You should notify your provider if your testes are firm, and egg shaped
C. If you feel a hard lump, wait 1 month and retest yourself
D. Perform the examination following a warm shower
Answer: D. Perform the examination following a warm shower
A nurse is providing teaching to the parents of a child who has varicella about management of
the disease. Which of the following instructions should the nurse include in the teaching?
A. Keep the child away from others until the skin is clear of scabs
B. Dress the child in warm clothing to promote healing of vesicles
C. Apply calamine lotion to vesicles on the child’s skin
D. Avoid giving the child a bath while vesicles are present
Answer: C. Apply calamine lotion to vesicles on the child’s skin
A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following
finding requires immediate intervention by the nurse should the nurse?
A. Dark brown blood noted in emesis
B. Frequent swallowing
C. Axillary temperature of 38 C (100 f)
D. Child reports pain level of 5 on the FACES scale
Answer: B. Frequent swallowing
A nurse is caring for a school age child who is 1 hour postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
A. Observe the child for frequent swallowing
B. Provide cranberry juice to the child
C. Maintain the child in a supine position
D. Discourage the child from coughing
E. Administer an analgesic to the child on a schedule basis
Answer: A. Observe the child for frequent swallowing
D. Discourage the child from coughing
E. Administer an analgesic to the child on a schedule basis
A nurse is teaching 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 your child indicates that he is tired before putting him to bed
B. Allow your child to watch an animated movie over night before bedtime
C. Wake your child up during the night terror
D. Avoid allowing you child to sleep in your bed
Answer: D. Avoid allowing you child to sleep in your bed
A nurse is caring for a client who is postoperative placement of a halo vest to manage a cervical
vertebral fracture. Which of the following actions should the nurse take?
A. Encourage flexion and extension of the neck
B. Assess the pin sites for injection once every other day
C. Reposition the client using a turning sheet
D. Tighten the screw on the halo device once-quarter turn every 48 hr.
Answer: C. Reposition the client using a turning sheet
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 ride the bicycle against the flow of traffic
B. Your child should walk the bicycle through intersections
C. Your child should keep the bicycle at least 3 feet from the curb while riding in the street
D. Your child’s feet should be 3 to 6 inches off the ground when seated on the bicycle
Answer: B. Your child should walk the bicycle through intersections
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. Clean around the stoma with full strength hydrogen peroxide
B. Place the child in Trendelenburg position when performing care.
C. Have the child flex his head when securing the ties.
D. Use clean technique to change the tracheostomy tube.
Answer: D. Use clean technique to change the tracheostomy tube.
A nurse is reviewing the laboratory results 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. Hyperactive bowel sounds
B. Hyporeflexia
C. Hypertension
D. Oliguria
Answer: A. Hyperactive bowel sounds
A nurse is reviewing 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. RBC Count 5/mm
B. Hemoglobin 6.8 g/dl
C. WBC count 15,000/mm
D. Platelet count 98,000/mm
Answer: A. RBC Count 5/mm
A nurse is caring for a child who has bacterial meningitis. Which of the following findings
should indicate to the nurse that the child can be removed from droplet precautions?
A. Antibiotics initiated 24 hr ago
B. Negative Cerebrospinal fluid culture
C. Absent nuchal rigidity
D. Temperature below 37.4 C (99.4F)
Answer: A. Antibiotics initiated 24 hr ago
A nurse is planning care for an adolescent following repair of Meckel Diverticulum. Which of
the following actions should the nurse include in the plan of care?
A. Administer total parenteral nutrition
B. Initiate long term antibiotic therapy
C. Maintain an Ng tube for decompression
D. Teach the client about ostomy care
Answer: C. Maintain an Ng tube for decompression
A nurse is caring for a school-age child who has pertussis. Which of the following actions should
the nurse take?
A. place the child in a protected environment for 48 hr (initiate droplet precautions for the child)
B. Report the diagnosis to the public health department
C. Administer the pertussis vaccine
D. Restrict oral fluids to 500 ml per day
Answer: A. place the child in a protected environment for 48 hr (initiate droplet precautions for
the child)
A nurse is providing education to a parent of a toddler who is experiencing a sickle cell crisis.
Which of the following statements by the parent indicates an understanding of the teaching?
A. "Administer furosemide IV twice per day"
B. " Apply warm compress to the affected areas""
C. " Initiate contact precautions
D. Decrease the child’s fluid intake
Answer: B. " Apply warm compress to the affected areas""
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. Change the IV site every 3 days
B. Cover the insertion site with an opaque dressing
C. Start the IV in the infant’s foot
D. Use a 24-gauge catheter to start the IV
Answer: D. Use a 24-gauge catheter to start the IV
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 repeat his childhood immunization once he is in remission
B. My child will need to double his medication for the next 6 months
C. I will ensure that my child is tested for tuberculosis every year
D. The risk of transmission decreases once my child is on zidovudine for 2 weeks
Answer: C. I will ensure that my child is tested for tuberculosis every year
A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse’s priority?
A. Sunken anterior fontanel
B. doll's eye reflex (sign that a comatose clients brainstem not intact
C. Potassium 5.1 mEq/L
D. Heart rate 162/min
Answer: B. doll's eye reflex (sign that a comatose clients brainstem not intact
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 may tolerate plain milk better than chocolate milk
B. You may replace milk with nondairy sources of calcium
C. You should consume flavored yogurt instead of plain yogurt
D. You can drink milk on an empty stomach
Answer: B. You may replace milk with nondairy sources of calcium
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. Use light touch when initiating conversation
C. Change positions frequently to maintain the child’s attention
D. Exaggerate the pronunciation of words
Answer: B. Use light touch when initiating conversation
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. Assist with intubation
B. Obtain an ABG sample
C. Administer an IV bolus
D. Apply warming blankets
Answer: A. Assist with intubation
A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which
of the following restraints should the nurse plan to use for this procedure?
A. Jacket
B. Mitten
C. Mummy (aka swaddling)
D. Elbow
Answer: C. Mummy (aka swaddling)
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 influence and pneumococcal vaccines for 24 month
B. Initiate a referral for chest physiotherapy every 4 hr.
C. Recommend the adolescent use a wheelchair to prevent stress the lower extremities
D. Encourage the adolescent to perform incentive spirometry to maintain lung capacity
Answer: C. Recommend the adolescent use a wheelchair to prevent stress the lower extremities
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following
findings is the nurse’s priority?
A. Cholesterol 189 mg/dl
B. Glycosuria
C. Preprandial blood glucose 124 mg/dl
D. HbA1c 11.5%
Answer: D. HbA1c 11.5%
