front 1 The nurse is caring for a 3 y.o. child who is 2 hours post-op from a cardiac catherization via the right femoral artery which assessment finding is an indication of arterial obstruction | back 1 Right foot is cool to the touch & appears pale and blanched |
front 2 Following a motor vehicle collision a 3 year old girl has a spica cast applied which toy is best for the nurse for this 3 year old child | back 2 Set cloth and hand puppets |
front 3 An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic which action should the nurse implement | back 3 Place the infant in a knee chest position |
front 4 A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? | back 4 Metabolic acidosis |
front 5 A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? | back 5 Serum potassium of 3.0 mg/dL |
front 6 The nurse is evaluating diet teaching for a client who has non tropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective? | back 6 Creamed corn. |
front 7 During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? | back 7 Object permanence. |
front 8 The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? | back 8 Palpate the anterior fontanel for tension and bulging. |
front 9 The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-old sibling are at the child’s bedside. Which instruction best supports family? | back 9 Please decide who will stay when the healthcare provider begins suturing. |
front 10 The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother? | back 10 Thicken formula with cereal for each feeding. |
front 11 While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors? | back 11 They provide the child with a sense of security. |
front 12 The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? | back 12 Repairs typically should be done before the child is potty trained. |
front 13 Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary consideration related to the disease? | back 13 Lemonade. |
front 14 The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? | back 14 Tachycardia. |
front 15 While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take? | back 15 Inquire about the use of alternative methods of treatment |
front 16 A child witch acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement? | back 16 Obtain specimen for blood cultures. |
front 17 A child who weighs 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many mg should the nurse administer to the child for each dose. | back 17 Ans. 300 x 25 = 7500/4 = 1875 |
front 18 The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement? | back 18 Notify the healthcare provider of the passage of brown stool. |
front 19 The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide? | back 19 Use a barrier cream, such as zinc oxide, which does not have to be completely |
front 20 Which statement by a school aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease? | back 20 I have to wear long sleeves and pants when we’re hiking around the pond |
front 21 The nurse is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective? | back 21 Laughs readily, turns from back to side. |
front 22 The HR for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, now it’s 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider? | back 22 BP70/40. |
front 23 A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure? | back 23 Describe the side-lying, knees to chest position that must be assumed during the procedure. |
front 24 The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) asks, “how can our son have this disease? We are wondering if we should have any more children.” What information should the nurse provide these parents? | back 24 This is an inherited x-linked recessive disorder, which primarily affects male children in the family. |
front 25 The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX the infant is still not breathing. Which action should the nurse take? | back 25 Give two breaths that makes the chest rise. |
front 26 A 3-year-old with HIV infections is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first? | back 26 Review the immunization documentation of the child who has HIV. |
front 27 A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is “beating a mile per minute.” Which information is most important for the nurse to obtain? | back 27 How often the MDI is used daily. |
front 28 The nurse is assessing a child for neurological soft signs, which finding is most likely demonstrated in the child’s behavior? | back 28 Poor coordination and sense of position. |
front 29 The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture? | back 29 Metabolic alkalosis. |
front 30 A 4-month-old girl brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? | back 30 Flaring of the nares. |
front 31 A two-year-old boy begins to cry when the mother starts to leave. What is the nurse’s best response in this situation? | back 31 Let me read this book to you. |
front 32 A two-year-old child with a heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? | back 32 Administer the scheduled dose. |
front 33 A child with leukemia is admitted for Chemotherapy and the nursing diagnosis “altered nutrition, less than body requirements related to anorexia, nausea and vomiting” is identified. Which intervention the nurse included in this child plan of care? | back 33 Allow the child to eat any food desired and tolerated. |
front 34 A 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings, which action should the nurse take first? | back 34 Administer a prescribed bronchodilator. |
front 35 The nurse plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weighs 55 pounds. Digoxin is available as elixir of 50 mcg/mL. How many mL of the digoxin elixir should the nurse administer to this child? | back 35 Ans. 55 lbs = 25 kg x 10 mcg = 250/50 = 5 |
front 36 The nurse observes a mother giving her 11-month-old ferrous sulfate, followed by two ounces of orange juice. What should the nurse do next? | back 36 Give positive feedback about the way she administered the sulfate. |
front 37 Which nursing intervention is the most important to include in the plan of care for a child with acute glomerulonephritis? | back 37 Weigh the child daily. |
front 38 During a well-baby visit, the parents explain that a soft bulge appears in the groin of their 4-month-old son when he cries or strains stooling. The infant is scheduled for surgical repair of the inguinal hernia in two weeks. The parent should be instructed to take which measures if the hernia becomes incarcerated prior to the surgery? | back 38 Gently manipulate the hernia for reduction. |
front 39 A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take? | back 39 Observe him carefully. |
front 40 The mother of a 9-month-old who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be alright to take her infant to the first b-day party of a friend’s child the following day. What response should the nurse provide this mother | back 40 Do not expose other children to RSV. It is very contagious even without direct contact. |
front 41 When screening a 5-year-old for strabismus, what action should the nurse take? | back 41 Direct the child through the six cardinal positions of gaze. |
front 42 The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse? | back 42 Demonstrate startle reflex. |
front 43 A child is brought to the clinic complaining of fever and joint pain and is diagnosed with rheumatic fever. When planning care for this child, what is the goal of nursing care? | back 43 Prevent cardiac damage. |
front 44 The nurse working on the pediatric unit takes two 8-year-old girls to the playroom.Which activity is best for the nurse to plan for these girls? | back 44 Selecting a board game. |
front 45 The nurse is developing the plan of care for a hospitalized child with Von Willebrand disease. What priority nursing intervention should be included in this child plan of care? | back 45 Guard against bleeding injuries. |
front 46 How should the nurse instruct the parents of a 4-month-old with seborrheic dermatitis(cradle cap) to shampoo the child’s hair? | back 46 Use a soft brush and gently scrub the area. |
front 47 Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest physiotherapy (CPT) that they will perform for their child at home. Which action requires intervention by the nurse? | back 47 The child is placed in a supine position to begin percussion. |
front 48 When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take? | back 48 Allow the child to initially play with the stethoscope to distract during auscultation. |
front 49 The mother of a one-month-old calls the clinic to report that the back of her infant is flat.How should the nurse respond? | back 49 Position the infant on the stomach occasionally when awake and active. |
front 50 Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children? | back 50 Carefully recording the height and weight of children to detect inappropriate growth. |
front 51 A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN).When obtaining the nursing history, which finding should the nurse expect to obtain? | back 51 A recent strep throat infection. |
front 52 The nurse plans to screen only the highest risk children for scoliosis. Which group of children should the nurse screen first? | back 52 Girls between ages 10 and 14. |
front 53 In assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most for the nurse to obtain? | back 53 Recent recurrence of infections. |
front 54 A 3-year-old boy in a daycare facility scratches his head frequently and the nurse confirms the presence of head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and call his parents. What instructions should the nurse provide to the parents about treatment of head lice? | back 54 Wash the child’s bed linens and clothing in hot soapy water. |
front 55 The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3- year-old son for wetting his pants. What initial action should the nurse take? | back 55 Inform the mother that toilet training is slower for boys. |