Professional Documents
Culture Documents
1. Totakethevitalsignsofa4montholdchild,whichorderprovidesthemostaccurate
results?
A.
Respiratoryrate,heartrate,thenrectaltemperature. Correct
B.
Heartrate,rectaltemperature,thenrespiratoryrate.
C.
Rectaltemperature,heartrate,thenrespiratoryrate.
D.
Rectaltemperature,respiratoryrate,thenheartrate.
ID:310947676
Therespiratoryrateshouldbetakenfirst(A)ininfants,sincetouchingthemorperforming
unpleasantproceduresusuallymakesthemcry,elevatingtheheartrateandmaking
respirationsdifficulttocount(B).Rectaltemperatureisthemostinvasiveprocedure,andis
mostlikelytoprecipitatecrying,soshouldbedonelast(CandD).
Awarded1.0pointsoutof1.0possiblepoints.
ID:311013607
2. A16yearoldisbroughttotheEmergencyCenterwithacrushedlegafterfallingoffa
horse.Theadolescent'slasttetanustoxoidboosterwasreceivedeightyearsago.Whatactionshould
thenursetake?
A.
Dispenseatetanusantitoxin.
B.
Preparehumantetanusimmuneglobulin.
C.
Administertetanustoxoidbooster. Correct
D.
Delaythetetanustoxoidboosteruntildue.
Afterthecompletionoftheinitialtetanusimmunizationschedule,therecommendedboosterfor
anadolescentoradultiseverytenyearsorlessifatraumaticinjuryoccursthatiscontaminated
bydirt,feces,soil,orsaliva,suchaspunctureorcrushinginjuries,avulsions,woundsfrom
missiles,burns,orfrostbite.Theadolescent'sinjuryisconsideredacontaminatedwound
requiringprophylactictherapy,sothetetanustoxoidboostershouldbeadministered(C).(A,B,
andD)arenotindicated.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310946642
3. Themotherofa6montholdasksthenursewhenherbabywillgetthefirstmeasles,
mumps,andrubella(MMR)vaccine.Basedontherecommendedchildhoodimmunizationschedule
publishedbytheCentersforDiseaseControl,whichresponseisaccurate?
A.
3to6months.
B.
12to15months. Correct
C.
18to24months.
D.
4to6years.
Thefirstmeasles,mumps,andrubella(MMR)vaccineshouldbegivennosoonerthan12
monthsofage,andideallybetween12and15monthsofage(B).(A)shouldnotreceivethe
MMRvaccineduetothepresenceofmaternalantibodies.MMRisnotroutinelyadministeredat
(C),butotherimmunizations,suchasDTaPandHepatitisBmaybegivenatthattime.The
seconddoseofMMRisroutinelyadministeredat(D),providedthatatleast4weekshave
elapsedsincethefirstdose,andifbothdoseswereadministeredbeginningatorafter12
months.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310945284
4. A2yearoldchildwithDownsyndromeisbroughttotheclinicforhisregularphysical
examination.ThenurseknowswhichproblemisfrequentlyassociatedwithDownsyndrome?
A.
Congenitalheartdisease. Correct
B.
FragileXchromosome.
C.
Trisomy13.
D.
Pyloricstenosis.
Congenitalheartdisease(A)isthemostcommonassociateddefectinchildrenwithDown
syndrome.(C)mighthaveseemedpossiblesinceDownsyndromeisatrisomalchromosomal
abnormalityofchromosome21.(B)isasexlinkedabnormalityalsocausingmentalretardation.
(D)isnotassociatedwithDownsyndrome.
Awarded1.0pointsoutof1.0possiblepoints.
5. A14yearoldfemaleclienttellsthenursethatsheisconcernedabouttheacneshehas
recentlydeveloped.Whichrecommendationshouldthenurseprovide?
A.
Removeallblackheadsandfollowwithanalcoholscrub.
B.
Usemedicatedcosmeticsonlytohelphidetheblemishes.
C.
Washthehairandskinfrequentlywithsoapandhotwater. Correct
D.
Encouragehertoseeadermatologistassoonaspossible. Incorrect
ID:310985655
Washingthehairandskinwithsoapandhotwater(C)removesoilanddebrisfromtheskinand
helpspreventandtreatacne.Oilyskinisespeciallybothersomeduringadolescencewhen
hormonescauseenlargementofsebaceousglandsandincreasedglandularsecretionswhich
predisposetheteenagertoacne.(A)iscontraindicated.Cosmetics("medicated"ornot)should
beusedsparinglytoavoidfurtherblockingsebaceousglandducts(B).(D)mightbeindicatedat
alatertime,ifhealthcarerecommendationsarenotsuccessful.
Awarded0.0pointsoutof1.0possiblepoints.
6. Thenurseiscaringfora12yearoldwithSyndromeofInappropriateAntidiuretic
Hormone(SIADH).Thischildshouldbecarefullyassessedforwhichcomplication?
A.
Poorskinturgorresultingfromdehydration.
B.
Changesinlevelofconsciousness. Correct
C.
Prematureagingasthediseaseprogresses.
D.
Severeedemafromanexcessofwaterandsodium. Incorrect
ID:310950702
Thechildmustbemonitoredforsignsandsymptomsofhyponatremia,whichcreatessecondary
centralnervoussystemalterationssuchaschangesinlevelofconsciousness,seizure,and
coma(B).FluidoverloadoccurswithSIADH,not(A)(whichoccurswithdiabetesinsipidus).(C)
iscausedbyhypersecretionofgrowthhormone,notSIADH.(D)isnotfoundinchildrenwith
SIADHbecauseedemaiscausedbyanexcessofbothwaterandsodium.
Awarded0.0pointsoutof1.0possiblepoints.
7. Athreemontholdboyweighing10lbs15ozhasanaxillarytemperatureof98.9F.The
nursedeterminesthedailycaloricneedforthischildisapproximately
A.
400caloriesperday.
B.
500caloriesperday.
C.
600caloriesperday. Correct
D.
700caloriesperday.
ID:310993975
10lbs15oz=10.9lbs.Convertlbstokgbydividingpoundsby2.210.9/2.2=4.954kg,
roundedto5kg.Aninfantrequires108calories/kg/day(1085=540calories/day).However,
thisinfantrequires10%morecaloriesbecausehehasonedegreetemperatureelevation.10%
of540is54and540+54=594.Thisinfantwillrequireapproximately600calories/day.Tough
question!Youknowthat400caloriesaretoofewand700aretoomuch,andatemperature
elevationnecessitatesconsumptionofmorecalories,sochoosethehigherofthetwochoices
left!
Awarded1.0pointsoutof1.0possiblepoints.
8. A6yearoldisadmittedtothepediatricunitafterfallingoffabicycle.Whichintervention
shouldthenurseimplementtoassistthechild'sadjustmenttohospitalization?
A.
Explainhospitalschedulestothechild,suchasmealtimes. Correct
B.
Useterms,suchas"honey"and"dear,"toshowacaringattitude.
C.
Providealistofrulesthatlimitsvisitationofsiblingsinthehospital.
D.
Orienttheparentstothehospitalunitandrefreshmentareas.
ID:310950708
Altereddailyschedulesandlossofritualsareupsettingtochildrenandincreaseseparation
anxiety,andactivesensitivitytotheneedsofchildrencanminimizethenegativeeffectsof
hospitalization.Explainingthehospitalschedules(A)andestablishinganindividualschedule
familiarizesthechildtothehospitalenvironmentanddecreasesanxiety.(B)depersonalizesthe
childwhoshouldbeaddressedbyname.Familyandsiblingvisitationshouldberecommended
andencouragedwithoutlimitation(C).Although(D)shouldbeimplemented,thedirect
involvementoftheschoolagedchildincorporatesthechild'ssenseofinitiateandcooperation.
Awarded1.0pointsoutof1.0possiblepoints.
9. Achildfallsontheplaygroundandisbroughttotheschoolnursewithasmalllaceration
ontheforearm.Whichactionshouldthenurseimplementfirst?
A.
Slowlypourhydrogenperoxideovertheopenwound.
B.
Applyicetotheareabeforerinsingwithcoldwater.
C.
Washthewoundgentlywithmildsoapandwater. Correct
D.
Gentlycleansewithasterilepadusingpovidoneiodine. Incorrect
ID:310965939
Asmall,superficiallacerationtotheskinshouldbewashedgentlywithmildsoapandwater(C)
forseveralminutes,followedbythoroughrinsing.(AandD)areantisepticsthatcanbe
traumatic(painful)whencleaningfresh,openwounds.Applyingice(B)mayreduceorprevent
furtheredema,butthewoundshouldbewashedwithmildsoapandwaterfirst.
Awarded0.0pointsoutof1.0possiblepoints.
Monitorforsignsofmetabolicacidosis.
B.
Estimatethequantityofdiarrheastools.
C.
Placeinasupinepositionafterfeeding.
D.
Observeforprojectilevomiting. Correct
Projectilevomiting(D),whichcontributestometabolicalkalosis(A),istheclassicsignofpyloric
stenosis.(B)isnotindicated.(C)isdangerous,duetothepotentialforaspirationwithfrequent
vomiting.
Awarded1.0pointsoutof1.0possiblepoints.
11. Whichclassofantiinfectivedrugsiscontraindicatedforuseinchildrenunder8yearsof
age?
A.
Aminoglycosides.
B.
Tetracyclines. Correct
C.
Penicillins.
D.
Quinolones.
ID:310959873
Tetracyclines(B)causeenamelhypoplasiaandtoothdiscolorationinchildrenunder8yearsof
age.(A,C,andD)arenotcontraindicatedforuseinchildren.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310957463
12. Thenurseispreparingahealthteachingprogramforparentsoftoddlersand
preschoolersandplanstoincludeinformationaboutpreventionofaccidentalpoisonings.Itismost
importantforthenursetoincludewhichinstruction?
A.
Tellchildrentheyshouldnottasteanythingbutfood.
B.
Storealltoxicagentsandmedicinesinlockedcabinets. Correct
C.
Providespecialplayareasinthehouseandrestrictplayinotherareas.
D.
Punishchildreniftheyopencabinetsthatcontainhouseholdchemicals.
Theonlyreliablewaytopreventpoisoningsinyoungchildrenistomaketheminaccessible(B).
Teachingchildrennottotasteisimportant(A),butineffectiveforyoungchildren.(CandD)will
notcontrolachild'scuriosity.
Awarded1.0pointsoutof1.0possiblepoints.
ID:311041550
13. Thenursereviewsthelatestlaboratoryresultsforachildwhoreceivedchemotherapy
lastweekandidentifiesareducedneutrophilcount.Whichnursingdiagnosishasthehighestpriorityfor
thischild?
A.
Riskforinfection. Correct
B.
Riskforhemorrhage.
C.
Alteredskinintegrity.
D.
Disturbanceinbodyimage.
Chemotherapy(CT)suppressesphagocytoticneutrophilsandplacesthechildatriskfor
infection(A),whichistheprioritynursingdiagnosis.(B,C,andD)mayberelatedtothecareof
achildreceivingCTarenotrelatedtoneutropenia.
Awarded1.0pointsoutof1.0possiblepoints.
14. Whichmenuselectionbyachildwithceliacdiseaseindicatestothenursethatthechild
understandsnecessarydietaryconsiderations?
A.
Ovenbakedpotatochipsandcola. Correct
B.
Peanutbutterandbananasandwich.
C.
Oatmealraisincookiesandmilk.
D.
Grahamcrackersandfruitjuice.
ID:310962721
Celiacdiseasecausesanintolerancetotheproteinglutenfoundinoats,rye,wheat,andbarley.
Thechildshouldavoidanyproductscontainingtheseingredientstoavoidsymptomssuchas
diarrhea.(A)istheselectionwhichavoidsalloftheseingredients.(B,C,andD)containgluten
inoneformoranother.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310955047
15. A12montholdboyisadmittedwitharespiratoryinfectionandpossiblepneumonia.He
isplacedinamisttentwithoxygen.Whichnursinginterventionhasthegreatestpriorityforthisinfant?
A.
Givesmall,frequentfeedingsoffluids.
B.
Accuratelychartobservationsregardingbreathsounds.
C.
Haveabulbsyringereadilyavailabletoremovesecretions. Correct
D.
Encourageoldersiblingstovisit.
Apatentairwayhasthehighestpriority.Humidificationwillliquefythenasalsecretionsthereby
increasingtheamountofsecretionsandmaking(C)thehighestpriority.(A)maintainshydration
andpreventtiring,butanopenairwayhasahigherpriority!(B)isimportantforevaluationof
therapy.Whenasked"priority"questions,REMEMBERMASLOW!Physicalneedsusuallyhave
ahigherprioritythanpsychosocialneeds(D)andanopenairwayisthehighestphysiological
need!
Awarded1.0pointsoutof1.0possiblepoints.
16. A6montholdinfantwithcongestiveheartfailure(CHF)isreceivingdigoxinelixir.Which
observationbythenursewarrantsimmediateintervention?
A.
Apicalheartrateof60. Correct
B.
Sweatingacrosstheforehead.
C.
Doesn'tsuckwell.
D.
Respiratoryrateof30breathsperminute.
ID:311018771
Aheartrateof60(A)ismuchlowerthannormalfora6montholdandwarrantsimmediate
intervention.Thenormalheartratefora6montholdis80to150BPMwhenawake,andarate
of70whilesleepingisconsideredwithinnormallimits.(BandC)areexpectedsymptomsof
heartfailureinaninfant.(D)iswithinnormallimitsforaninfant.
Awarded1.0pointsoutof1.0possiblepoints.
17. Whenassessingachildwithasthma,thenurseshouldexpectintercostalretractions
during
A.
inspiration. Correct
B.
coughing. Incorrect
C.
apneicepisodes.
D.
expiration.
Intercostalretractionsresultfromrespiratoryefforttodrawairintorestrictedairways(A).
Awarded0.0pointsoutof1.0possiblepoints.
ID:310947664
18. Achildwithcysticfibrosisishavingstoolsthatfloatandarefoulsmelling.Which
descriptivetermshouldthenurseusetodocumentthefinding?
A.
Diarrhea.
B.
Rhinorrhea.
C.
Galactorrhea.
D.
Steatorrhea. Correct
ID:311041544
Steatorrhea(D)isdefinedasstoolswithanabnormallyhighfatcontentthatareusuallyfoul
smellingandfloatonwater.(A,B,andC)donotdescribethisfinding.
Awarded1.0pointsoutof1.0possiblepoints.
19. Thenursereceivesalabreportstatingachildwithasthmahasatheophyllinelevelof15
mcg/dl.Whatactionwillthenursetake?
A.
Passtheinformationoninthereport. Correct
B.
Notifythehealthcareproviderbecausethevalueishigh.
C.
Repeatthelabstudybecausethevalueistoohigh.
D.
Holdthenextdoseoftheophylline.
ID:311018767
Thetherapeuticleveloftheophyllineis10to20mcg/dl,sothechild'sleveliswithinthe
therapeuticrange.Thisinformationevaluatestheprescribedtherapyandshouldbe
communicatedinthenurse'sreport(A).(B,C,andD)wouldbeinappropriateactionsinviewof
thelaboratoryfinding.
Awarded1.0pointsoutof1.0possiblepoints.
Weighingdiapers.
B.
Assessingfontanels. Correct
C.
Checkingskinturgor.
D.
Observingmucousmembranesformoisture.
Alloftheseinterventionsevaluatefluidstatusininfants.But,howoldisthischild?Posterior
fontanelclosesat2monthsandanteriorfontanelclosesby18monthsofage(B)!Remember
normalgrowthanddevelopment!
Awarded1.0pointsoutof1.0possiblepoints.
21. Thenurseisplanningcareforschoolagedchildrenatacommunitycarecenter.Which
activityisbestforthechildren?
A.
Buildingmodelairplanes. Incorrect
B.
Playingfollowtheleader. Correct
C.
Stringinglargeandsmallbeads.
D.
PlayingwithPlaydoughandclay.
ID:310946672
Schoolagedchildrenstriveforindependenceandproductivity(Erikson'sIndustryvs.Inferiority)
andenjoyindividualandgroupactivitiesrelatedtoreallifesituations,suchasplayingfollow
theleader(B).(A)isanindividualactivitythatcouldcontributetofeelingsofinferiorityand
inadequacyifthetaskistoocomplex.Althoughschoolagedchildrenenjoycrafts,(CandD)are
moreappropriateforpreschoolchildren.
Awarded0.0pointsoutof1.0possiblepoints.
22. Whichrestraintshouldbeusedforatoddlerafteracleftpalaterepair?
A.
Clovehitch.
B.
Mummy.
C.
Elbow. Correct
D.
Jacket.
ID:310955019
Elbowrestraintspreventchildrenfrombendingtheirarmsandbringingtheirhandstotheoral
surgicalsite.(A)restrainsthehands,butthechildcanbendandbringtheirheadtotheirhands.
(B)isusedduringprocedures.(D)restrainsthebodytorsoandisnotappropriate.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310999069
23. Aburnedchildisbroughttotheemergencyroom.Inestimatingthepercentageofthe
bodyburned,thenurseusesamodified"RuleofNines."Whichpartofachild'sbodyiscalculatedasa
largerpercentageoftotalbodysurfacethananadult's?
A.
Headandneck. Correct
B.
Armsandchest.
C.
Legsandabdomen.
D.
Backandabdomen. Incorrect
Achild'sheadandneckareproportionatelylargertotheirbodythananadult's(A).The
standard"RuleofNines"isinaccuratefordeterminingburnedbodysurfaceareaswithchildren,
andmustbemodifiedforusewithchildren.Speciallydesignedchartsforchildrenarecommonly
usedtodeterminebodysurfaceareainvolvement.(B,C,andD)arenotproportionately
different.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310950716
24. Thevitalsignsofa4yearoldchildwithpolyuriaare:BP80/40,Pulse118,and
Respirations24.Thechild'spedalpulsesarepresentwithavolumeof+1,andnoedemaisobserved.
Whatactionshouldthenurseimplementfirst?
A.
Insertanindwellingurinarycatheter.
B.
StartanIVinfusionofnormalsaline. Correct
C.
Sendaspecimentothelabforurinalysis.
D.
Documentthechild'svitalsignsandpulses. Incorrect
Thecurrentvitalsignreadingsandthedecreasedperipheralpulsevolumeindicatethatthe
childisexperiencingfluidvolumedeficitduetothepolyuria,sothepriorityactionistorestore
fluidvolume(B).(A)isusefulinobtainingapreciseurineoutputmeasure,butisalowerpriority
thanrestoringfluidvolumeatthistime.(C)isnotindicatedbasedonthecurrentassessment
data,and(D)doesnotrecognizetheneedforimmediateactiontocombatthefluidvolume
deficit.
Awarded0.0pointsoutof1.0possiblepoints.
25. Thenurseisteachingamothertogive4mlofaliquidantibiotictoa10montholdinfant.
Whichstatementbytheparentindicatesaneedforfurtherteaching?
A.
Iwillgivethisantibiotictomychilduntilitisfinished.
B.
Usingateaspoonwillhelpmemeasurethiscorrectly. Correct
C.
Iwillcalltheclinicifmychilddevelopsarashoritching.
D.
Mybabyshouldbegintofeelbetterwithinafewdays. Incorrect
ID:310957445
Theprescribedmedicationis4mlperdosageandismeasuredwiththemostaccuracyusinga
syringe,soiftheparentusesateaspoon(B),whichisequivalentto5ml,furtherteachingis
indicated.(A,C,andD)indicatecorrectunderstandingandrequirenofurtherinterventionbythe
nurse.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310945716
26. A4yearoldboywasadmittedtotheemergencyroomwithafracturedrightulnaanda
shortarmcastisapplied.Whenpreparingtheparentstotakethechildhome,whichdischarge
instructionhasthehighestpriority?
A.
B.
Callthehealthcareproviderimmediatelyifhisnailbedsappearblue. Correct
Checkhisfingershourlyforthefirst48hourstoseethatheisabletomovethemwithout
pain.
C.
Besurehisarmremainsabovehisheartforthefirst24hours.
D.
Takehistemperatureq4hforthenexttwodaysandcallifanelevationisnoted.
Cyanosis(A)indicatesimpairedcirculationtofingersandshouldbereportedimmediately.
Althoughtheactionsdescribedin(B,C,andD)maybeindicated,theyareimplementedrather
excessivelyandmighttendtofrightentheparents.Itisnotnecessarytocheckthechild's
abilitytomovehisfingershourlyfor2days(B).Elevatingthearmabovetheheartwillhelpto
decreaseswellingbut(C)isstatedinafrighteningway.Itisnotnecessarytotakethechild's
temperatureq4hunlessindicatedbyothersymptoms.
Awarded1.0pointsoutof1.0possiblepoints.
27. A3yearoldboyisbroughttotheemergencyroombecauseheswallowedanentire
bottleofchildren'svitaminpills.Whichinterventionshouldthenurseimplementfirst?
A.
InsertN/Gtubeforgastriclavage.
B.
Determinethechild'spulseandrespirations. Correct
C.
Assessthechild'slevelofconsciousness. Incorrect
D.
AdministeranIVD5/0.25NSasprescribed.
ID:311018743
Themostimportantprincipleindealingwithapoisoningistotreatthechildfirst,notthepoison.
Initiateimmediatelifesupportmeasureswithassessmentofvitalsigns(B),inparticular,
respirations.Insertinganairwayorinitiatingmechanicalventilationmaybenecessary.
Assessmentandidentificationofthepoisonshouldoccurpriorto(A).(CandD)shouldoccur
afterassessingtheairway.
Awarded0.0pointsoutof1.0possiblepoints.
Aplastic.
B.
Sequestration. Correct
C.
Hyperhemolytic. Incorrect
D.
Vasoocclusive.
Thefindingssupportasequestrationcrisis(B),wherebloodpoolsinthespleen,andis
characterizedbyabdominalpainandanemia.(AandC)crisesproduceanemiabutno
abdominalpainorsplenicenlargement.(D)crisismayproduceabdominalpain,butnosplenic
enlargementorexacerbationofanemia.
Awarded0.0pointsoutof1.0possiblepoints.
29. A2yearoldchildwithgastroesophagealrefluxhasdevelopedafearofeating.What
instructionshouldthenurseincludeintheparents'teachingplan?
A.
Inviteotherchildrenhometosharemeals.
B.
Acceptthathewilleatwhenheishungry.
C.
Rewardthechildwithanapaftereating.
D.
Consistentlyfollowasetmealtimeroutine. Correct
ID:311018749
A2yearoldchildiscomfortedbyconsistency(D).(A)iscontraindicatedbecausetwoyearolds
mayparticipateinparallelactivitieswithotherchildrenbutaretooyoungtofeelcomfortand
supportbythepresenceofotherchildrenwhenanxiousorafraid.(B)mayormaynotbetrue
anddoesnotaddressthechild'sfears.Thechildwithrefluxshouldremainuprightatleasttwo
hoursaftereating(C)toreducesymptoms.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310972799
30. Thenurseisgivingpreoperativeinstructionstoa14yearoldfemaleclientwhois
scheduledforsurgerytocorrectaspinalcurvature.Whichstatementbytheclientbestdemonstrates
thatlearninghastakenplace?
A.
Iwillreadalltheliteratureyougavemebeforesurgery.
B.
IhavehadsurgerybeforewhenIbrokemywristinabikeaccident,soIknowwhattoexpect.
C.
Allthethingspeoplehavetoldmewillhelpmetakecareofmyback.
D.
IunderstandthatIwillbeinabodycastandIwillshowyouhowyoutaughtmeto
turn. Correct
Outcomeoflearningisbestdemonstratedwhentheclientnotonlyverbalizesanunderstanding
butcanalsoprovideareturndemonstration(D).A14yearoldmayormaynotfollowthrough
with(A),andthereisnomeasurementofthatlearning.Havingprevioussurgery(B)mayhelp
theclientunderstandthesurgicalprocess,butwristsurgeryisverydifferentfromspinalsurgery
andemergencysurgeryisdifferentfromelectivesurgery.In(C),theclientmaybesayingwhat
thenursewantstohear,withoutexpressinganyrealunderstandingofwhattodoaftersurgery.
Awarded1.0pointsoutof1.0possiblepoints.
31. A2yearoldchildrecentlydiagnosedwithhemophiliaAisdischargedhome.What
informationshouldthenurseincludeinateachingplanabouthomecare?
ID:311041548
A.
Minimizeinteractiveplaywithotherchildrentolessenchancesforinjury.
B.
Givelowdosechildren'schewableaspirininorangeflavorforjointdiscomfort.
C.
Useafirmanddrytoothbrushtocleanteethatleasttwiceperday.
D.
Applypressureandiceforbleedingwhileelevatingandrestingtheextremity. Correct
Hemophilia,ablooddisorder,causesjointbleedingwhichistreatedwithrest,ice,compression,
andelevation(RICE)(D).(A,B,andC)areinaccurate.
Awarded1.0pointsoutof1.0possiblepoints.
32. Thenurseisassessingan8montholdchildwhohasamedicaldiagnosisofTetrologyof
Fallot.Whichsymptomisthisclientmostlikelytoexhibit?
A.
Bradycardia.
B.
Machinerymurmur.
C.
Weakpedalpulses.
D.
Clubbedfingers. Correct
ID:311002933
TetrologyofFallot,acyanoticheartdefect,causesclubbingoffingersandtoes(D)dueto
tissuehypoxia.Tachycardia,not(A),isamanifestationofcongenitalheartdisease.(B)isa
classicsignofventricularseptaldefect.(C)ischaracteristicofcoarctationoftheaorta.
Awarded1.0pointsoutof1.0possiblepoints.
ID:311028943
33. Aprematurenewborngirl,born24hoursago,isdiagnosedwithapatentductus
arteriosus(PDA)andplacedunderanoxygenhoodat35%.Theparentsvisitthenurseryandaskto
holdher.Whichresponseshouldthenurseprovidetotheparents?
A.
Studieshaveshownthathandlingasicknewbornisnotgoodforthebabyandupsetsthe
parents.
B.
Theoxygenhoodisholdingthebaby'soxygenleveljustatthepointwhichisneeded.You
maystrokeandtalktoher. Correct
C.
Sinceyourbabyhasbeendoingwellunderoxygenfor24hours,Icanletyouholdthebaby
withoutoxygen.
D.
Youcanholdthebabywiththeoxygenblowinginthebaby'sfacesincethelevelisvery
closetoroomair.
Thebabyisat35%whichismuchmorethanroomair(21%)andatthistimethebabyshould
notbemovedfromunderthehood.Thenurseshouldoffertheparentsanalternativesuchasto
strokeandreassuretheinfant(B).Holdingsickbabiesbenefitstheinfantandtheparents(A).
Thefirstconsiderationnowhastobetheinfant'soxygenation.Thenurseshouldnottakethe
babyoutfromunderthehoodwithoutaprescriptionfromthehealthcareprovider,asthiscould
severelycompromisetheinfant(C).APO2of35%cannotbereadilyachievedwith"blowby"
oxygen(D).
Awarded1.0pointsoutof1.0possiblepoints.
34. Toassesstheeffectivenessofananalgesicadministeredtoa4yearold,what
interventionisbestforthenursetoimplement?
A.
Useahappyface/sadfacepainscale. Correct
B.
Askthemotherifshethinkstheanalgesicisworking.
C.
Assessforchangesinthechild'svitalsigns.
D.
Teachthechildtopointtoanumericpainscale.
ID:310965949
A4yearoldcanreadilyidentifywithsimplepictures(A)toshowthenursehowhe/sheis
feeling.(B)couldbeusedtovalidatewhatthechildistellingthenurseviathe"faces"pain
scale,butitisbesttoelicitthechild'sassessmentofhis/herpainlevel.(C)maynotaccurately
reflecttheeffectivenessofpainmedicationastheycanalsobeaffectedbyothervariables,
suchasfear.(D)requiresabstractnumberskillsbeyondthelevelofa4yearold.
Awarded1.0pointsoutof1.0possiblepoints.
Parentalcontrolshouldbeconsistent. Correct
B.
Childrenasyoungas4yearsrarelyneedreprimandorpunishment.
C.
Withdrawalofapprovaliseffective.
D.
Parentsshouldenforcerigidrulestobefollowedwithoutquestion.
Disciplineshouldbeapositiveandnecessarycomponentofchildrearingthatisstartedin
infancyandshouldteachsociallyacceptablebehavior,helpchildrenprotectthemselvesfrom
danger,andchannelundesirablebehaviorintoconstructiveactivity.Misbehaviormayresult
frominconsistentrulesormessages,soparentalattentionshouldbeclear,reasonable,and
consistent(A).(BandC)arenothelpfultothechild.Childrenneedboundariesthatarefirmbut
notrigid(D).
Awarded1.0pointsoutof1.0possiblepoints.
36. Thenurseisassessinga13yearoldgirlwithsuspectedhyperthyroidism.Which
questionismostimportantforthenursetoaskherduringtheadmissioninterview?
A.
Haveyoulostanyweightinthelastmonth?
B.
Areyouexperiencinganytypeofnervousness? Correct
C.
Whenwasthelasttimeyoutookyoursynthroid?
D.
Areyouhavinganyproblemswithyourvision?
ID:310947670
Assessingtheclient'sphysiologicalstateuponadmissionisapriority,andnervousness,
apprehension,hyperexcitability,andpalpitationsaresignsofhyperthyroidism(B).Weightloss
(evenwithaheartyappetite)(A)occursinthosewithhyperthyroidism,butassessingtheclient's
neurologicalstatehasahigherpriority.Hormonereplacementisnotadministeredtoaclient
whoisalreadyproducingtoomuchthyroid(C).Theclientmayhaveexophthalmus(bulging
eyes)buthyperthyroidismdoesnotcausevisionproblems(D).
Awarded1.0pointsoutof1.0possiblepoints.
ID:310965995
37. Ahospitalized16yearoldmalerefusesallvisitsfromhisclassmatesbecauseheis
concernedabouthisdistortedappearance.Toincreasetheclient'ssocialinteraction,whatintervention
isbestforthenursetoinitiate?
A.
Encouragetheclienttouseahandheldvideogamethatispopularwithallhisfriends.
B.
Assigna25yearoldfemalenursingstudenttooffersupporttotheclient.
C.
ArrangeforanInternetconnectionintheclient'sroomforemailcommunication. Correct
D.
Encouragetheclient'smothertoarrangeasurprisegettogetherinthecafeteria.
Bodyimageandpeeracceptancearekeyconcernsfortheadolescent.(C)allowsforsocial
interactionwithoutfacetofacecontact,thusprotectinghisselfimagewhilealsopromoting
socialinteraction.(A)doesnotpromotesocialinteraction.(B)doesnotencourageinteraction
withhisownpeergroup,whichisofgreaterimportance.(D)doesnotrespecttheclient's
concernabouthisbodyimage.
Awarded1.0pointsoutof1.0possiblepoints.
38. Thenurseisassessinga2yearold.Whatbehaviorindicatesthatthechild'slanguage
developmentiswithinnormallimits?
A.
Isabletonamefourcolors.
B.
Cancountfiveblocks.
C.
Iscapableofmakingathreewordsentence. Incorrect
D.
Halfofchild'sspeechisunderstandable. Correct
ID:310993913
Betweenapproximately15and24monthsofage,achild'sspeechisonlyhalfunderstandable
(D).(AandB)usuallyoccurbetween3and5yearsofage.(C)isusuallyaccomplishedby18
monthsofage.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310950766
39. Whenevaluatingtheeffectivenessofinterventionstoimprovethenutritionalstatusofan
infantwithgastroesophagealreflux,whichinterventionismostimportantforthenursetoimplement?
A.
Recordweightdaily. Correct
B.
Assessforsignsofanemia.
C.
Documentsleepingpatterns.
D.
Teachparentingskills.
Themostdefinitivemeasureofimprovednutritioninaninfantisobtainingthechild'sdaily
weight(A).(B,C,andD)mayalsobeuseful,buttheyarenotasdefinitiveasadailyweight
measurement.
Awarded1.0pointsoutof1.0possiblepoints.
B.
Childrenneedtoretainasenseofinitiativewithoutimpingingontherightsandprivilegesof
others. Correct
Negativefeelingsofdoubtandshamearecharacteristicof4yearoldchildren.
C.
Roleconflictisacommonproblemofchildrenthisage.Sheisjustwonderingwhereshefits
intosociety.
D.
Atthisagechildrencompeteandliketoproduceandcarrythroughwithtasks.Sheisjust
competingwithhermother. Incorrect
Childrenaged3to6areinErickson's"Initiativevs.Guilt"stage,whichischaracterizedby
vigorous,intrusivebehavior,enterprise,andstrongimagination.Atthisage,childrendevelopa
conscienceandmustlearntoretainasenseofinitiativewithoutimpingingontherightsof
others(A).(B)describesthe"Autonomyvs.ShameandDoubt,"stage(1to3yearsofage).(C)
describesanadolescent(12to18yearsofage),the"Identityvs.RoleConfusion"stage.(D)
describesachild6to12yearsofage,the"Industryvs.Inferiority"stage.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310953425
41. Aninfantisbornwithaventricularseptaldefect(VSD)andsurgeryisplannedtocorrect
thedefect.Thenurserecognizesthatsurgicalcorrectionisdesignedtoachievewhichoutcome?
A.
Stoptheflowofunoxygenatedbloodintosystemiccirculation.
B.
Increasetheflowofunoxygenatedbloodtothelungs.
C.
Preventthereturnofoxygenatedbloodtothelungs. Correct
D.
Reduceperipheraltissuehypoxiaandnailbedclubbing.
ClosureofVSDsstopsoxygenatedbloodfrombeingshuntedfromtheleftventricletotheright
ventricle(C).VSDsareacyanoticdefects,whichmeansthatnounoxygenatedbloodentersthe
systemiccirculation(AandB).(D)iscommonwithTetrologyofFallot,whichisacyanotic
defect.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310946616
42. A5montholdisadmittedtothehospitalwithvomitinganddiarrhea.Thepediatrician
prescribesdextrose5%and0.25%normalsalinewith2mEqKCl/100mltobeinfusedat25ml/hour.
Priortoinitiatingtheinfusion,thenurseshouldobtainwhichassessmentfinding?
A.
Frequencyofemesisinthelast8hours.
B.
SerumBUNandcreatininelevels. Correct
C.
Currentbloodsugarlevel. Incorrect
D.
Appearanceofthestool.
Regardlessofaclient'sage,adequaterenalfunctionmustbepresentbeforeaddingpotassium
toIVfluids(B).(A)isimportantindeterminingtheneedforfluidreplacement.(C)isnot
indicated.(D)isusefulinformation,butwillnotimpactadministrationoftheprescribedIV
solution.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310969421
43. A6montholdboyandhismotherareatthehealthcareprovider'sofficeforawellbaby
checkupandroutineimmunizations.Thehealthcareproviderrecommendstothemotherthatthechild
receiveaninfluenzavaccine.Whatmedicationsshouldthenurseplantoadministertoday?
A.
Theroutineimmunizationsandscheduleanotherappointmenttoadministertheinfluenza
vaccine.
B.
Alltheimmunizationswiththeinfluenzavaccinegivenataseparatesitefromanyother
injection. Correct
C.
Theinfluenzavaccineandscheduleanotherappointmenttoadministertheimmunizations.
D.
Theinfluenzavaccineandthepoliovaccineandscheduleanotherappointmenttoadminister
theremainingimmunizations.
At6monthsofage,theroutineimmunizationsincludeHepatitisB,DTaP,Hib(Haemophilus
influenzatypeb),PCV(Pneumococcal),IPV(inactivatedpoliovirus)andinfluenza.The
influenzavaccineshouldbegivenataseparatesitefromanyotherinjection(B).Schedulinga
returnvisit(A,B,orC)increasestheriskthatthemotherwillnotbringthechildbackforthe
immunizations.
Awarded1.0pointsoutof1.0possiblepoints.
44. Duringdischargeteachingofachildwithjuvenilerheumatoidarthritis,thenurseshould
stresstotheparentstheimportanceofobtainingwhichdiagnostictesting?
A.
Hearingtests.
B.
Eyeexams. Correct
C.
Chestxrays.
D.
Fastingbloodglucosetests. Incorrect
ID:310993917
VisualchangesleadingtoblindnesscanoccurinchildrenwithJRA.Regulareyeexams(B)can
helptopreventthiscomplication.(A,C,andD)arenotroutinelynecessaryformanagementof
JRA.
Awarded0.0pointsoutof1.0possiblepoints.
45. Whentakingthehealthhistoryofachild,thenurseknowsthatwhichfindingisanearly
indicationofhypothyroidisminchildren?
A.
Hyperactivebehavioraltraits.
B.
Delayintheeruptionofpermanentteeth.
C.
Slowsexualdevelopment,butwithinnormalrange. Incorrect
D.
Cessationofgrowthinachildthathadbeennormal. Correct
ID:311018707
Sincethethyroidglandisresponsibleformetabolism,cessationofgrowth(D)whichwas
previouslywithinnormalrange,isthemostcommonsignforhypothyroidisminchildren.The
childwithhypothyroidismislikelytobeHYPOactive,not(A).Although(BandC)mayoccurwith
hypothyroidism,theyarelatesigns(notearlyindications)andaresignsmoreoftenassociated
withalackofgrowthhormone.
Awarded0.0pointsoutof1.0possiblepoints.
46. Aspartofthephysicalassessmentofchildren,thenurseobservesandpalpatesthe
fontanels.Whichchild'sfontanelfindingshouldbereportedtothehealthcareprovider?
A.
A6montholdwithfailuretothrivethathasaclosedanteriorfontanel. Correct
B.
A24montholdwithgastroenteritisthathasaclosedposteriorfontanel.
C.
A2montholdwithchickenpoxthathasanopenposteriorfontanel.
D.
A28montholdwithhydrocephalusthathasanopenanteriorfontanel. Incorrect
ID:311023645
Atsixmonthsofagetheanteriorfontanelshouldbeopen,anditshouldnotbecloseduntil
approximately18monthsofage.(BandC)arenormalfindings.Achildwithhydrocephalusmay
haveadelayedclosingofthefontanel(D).
Awarded0.0pointsoutof1.0possiblepoints.
ID:310999065
47. Thenurseisteachinga12yearoldmaleadolescentandhisfamilyabouttaking
injectionsofgrowthhormoneforidiopathichypopituitarism.Whichadversesymptoms,commonly
associatedwithgrowthhormonetherapy,shouldthenurseplantodescribetothechildandhisfamily?
A.
Polyuriaandpolydipsia. Correct
B.
Lethargyandfatigue.
C.
Increasedfacialhair. Incorrect
D.
Facialbonestructurechanges.
Signsandsymptomsofdiabetesorhyperglycemia(A)needtobereported.Thosereceiving
growthhormoneshouldbemonitoredtodetectelevatedbloodsugarsandglucoseintolerance.
(B)isassociatedwithanynumberofheathalterations,butisnotassociatedwiththegrowth
hormonetherapy.(CandD)arenormalchangesthatoccurwith12yearoldmales.
Awarded0.0pointsoutof1.0possiblepoints.
48. Theparentsofa3weekoldinfantreportthatthechildeatswellbutvomitsaftereach
feeding.Whatinformationismostimportantforthenursetoobtain?
A.
Descriptionofvomitingepisodesinpast24hours. Correct
B.
Numberofwetdiapersinlast24hours. Incorrect
C.
Feedingandsleepschedule.
D.
Amountofformulaconsumedduringthepast24hours.
ID:310999043
Adescriptionofthevomitingepisodes(A)willassistthenurseindeterminingthereasonforthe
symptoms,whichmaybehelpfulindevelopingaplanofcareforthisinfant.(BandC)provide
relatedinformationbutarenotashelpfulas(A).(D)mayberelatedtothevomiting,butthe
nurseshouldfirstobtainabetterdescriptionofthevomitingepisodes.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310950768
49. An18montholdisadmittedtothehospitalwithpossibleHirschsprungsdisease.When
obtaininganursinghistory,thenurseasksaboutbowelhabits.Whatdescriptionofthedisease?
A.
Foulsmellingandfatty.
B.
Bilecoloredandwatery. Incorrect
C.
Semisolidandyellow.
D.
Ribbonlikeandbrown. Correct
Hirschsprungsdiseaseisamechanicalobstructioncausedbyinadequatemotilityinapartof
theintestines.Theconditionresultsfromfailureofganglioncellstomigratecraniocaudally
alongtheGItractduringgestation.Thelackofperistalsisintheaffectedbowelsegmentcauses
constipationandsmalldiameter,browncoloredstools(D).(A)isassociatedwithcysticfibrosis.
(B)iscommoningastroenteritis.(C)isnormalinbreastfedneonates.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310944082
50. A17yearoldmalestudentreportstotheschoolcliniconemorningforascheduled
healthexam.Hetellsthenursethathejustfinishedfootballpracticeandisonhiswaytoclass.The
nurseassesseshisvitalsigns:temperature100F,pulse80,respirations20,andbloodpressure
122/82.Whatisthebestactionforthenursetotake?
A.
Tellthestudenttoproceeddirectlytohisregularlyscheduledclass. Correct
B.
Calltheparentandsuggestretakingthestudent'stemperatureathome.
C.
Givethestudentaglassofcoolfluids,thenretakehistemperature.
D.
Sendthestudenttoclass,butreverifyhistemperatureafterlunch.
Thisstudenthasjustcompletedfootballpractice,andincreasedmuscleactivityincreasesbody
heatproduction.Atemperatureof100Fisnormalforthisstudentatthistime.Thestudent
shouldattendclass(A)sincenofurthernursingactionisrequired.(B)wouldalarmtheparents
unnecessarily.(C)wouldprovideafalsereadingofbodytemperature.(D)isunnecessarysince
thesefindingsarewithinnormallimits.
Awarded1.0pointsoutof1.0possiblepoints.
51. Whichfindingina19yearoldfemaleclientshouldtriggerfurtherassessmentbythe
nurse?
A.
Menstruationhasnotoccurred. Correct
B.
Reportsnotetanusimmunizationsincechildhood.
C.
Denieshavinganywisdomteeth.
D.
Historyofpainful,inwardgrowthonbottomoffoot.
ID:311008915
Menstruationisanexpectedsecondarysexcharacteristicthatoccurswithpubescenceand
typicallyoccursbyage18,so(A)shouldpromptfurtherinvestigationtodeterminethecauseof
thisprimaryamenorrhea.ChildrenreceivetetanusaspartoftheDPTchildhoodimmunization
series,andaboosterisnottypicallygivenuntilage16(B).Wisdomteetharethethirdmolar
teethofthepermanentdentitionandarethelasttoerupt,so(C)isanormalfinding.(D)
describesaplantarsurfacewart,harmlessbutpainfulbecauseofthepressurewithwalkingor
standing.
Awarded1.0pointsoutof1.0possiblepoints.
52. Duringadministrationofabloodtransfusion,achildcomplainsofchills,headache,and
nausea.Whichactionshouldthenurseimplement?
A.
StartanotherIVofdextrosesolutionandstaywiththechild.
B.
Continuethetransfusionandmonitorthechildsvitalsigns.
C.
Stoptheinfusionimmediatelyandnotifythehealthcareprovider. Correct
D.
Slowthetransfusionandassessforcessationofsymptoms.
ID:310953451
Thechildisexhibitingsignsofareactiontothebloodtransfusion.Thebloodtransfusionshould
bestoppedimmediatelyandthehealthcareprovidernotified(C).Afterthetransfusionis
discontinued,IVaccessshouldbemaintained(A)withfluidsthatdonotintroduceanymore
cellularproducts.(BandD)placethechildatriskforfurtherbloodreactions.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310972757
53. Themotherofa2yearoldboyconsultsthenurseaboutherson'sincreasedtemper
tantrums.Themotherstates,"Yesterdayhethrewafitinthegrocerystore,andIdidnotknowwhatto
do.Iwassoembarrassed.WhatcanIdoifthisoccursagain?"Whichrecommendationisbestforthe
nursetoprovidethismother?
A.
Paddlehimgentlyassoonasthebehaviorisinitiated. Incorrect
B.
Immediatelyputhimin"timeout."
C.
Quietlyremindhimthatothersarewatchinghim.
D.
Walkawayfromhimandignorethebehavior. Correct
Thebestapproachforatoddleristoignoretheattentionseekingbehavior(D).Theparent
shouldbesomewhatnearby,withinviewofthechildbutshouldavoidreinforcingthebehaviorin
anyway.Tantrumscansometimesbeavoidedbytalkingtothechildbeforethesituation
occurs.(A,B,andC)wouldallprovideattentionfortheinappropriatebehavior.
Awarded0.0pointsoutof1.0possiblepoints.
ID:311041542
54. Anurseprovidestheparentswithinformationonhealthmaintenancefortheirchildwith
sicklecelldisease.Whichinformationreflectedbytheparentsindicatesunderstandingofthechild's
care?
A.
Dailyironsupplementsshouldbegiven. Incorrect
B.
Plentyoffluidsshouldbeconsumeddaily. Correct
C.
Immunizationsshouldbedelayedforafewyears.
D.
Protectiveequipmentshouldbewornforcontactsports.
Adequatefluidintake(B)decreasestheviscosityofthebloodwhichaffectstheincidenceof
vasocclusivecrisis.(AandD)arenotcommonlyindicatedforachildwithsicklecelldisease.A
routineimmunizationschedule(C)isrecommendedforachildrenwithSCDbecauseoftheir
increasedsusceptibilitytoinfectionthatpredisposestosicklingphenomena.
Awarded0.0pointsoutof1.0possiblepoints.
55. Whichmeasurementsshouldbeusedtoaccuratelycalculateapediatricmedication
dosage?(Selectallthatapply.)
A.
Child'sheightandweight. Correct
B.
Adultdosageofmedication. Incorrect
ID:310965927
C.
Bodysurfaceareaofchild. Correct
D.
Averageadult'sbodysurfacearea. Incorrect
E.
Averagepediatricdosageofmedication.
F.
Nomogramdeterminedmathematicalconstant. Correct
Correctselectionsare(A,C,andF).Themostaccuratecalculationsofpediatricdosagesuse
thechild'sheightandweight(A).Thechild'sBSAiscalculatedusingthesquarerootofweight
inkgtimesheightincmdividedby3600orthesquarerootofweightinlbtimesheightininches
dividedby3131(C),thenthechild'sBSAismultipliedbytherecommendedpublisheddoseper
BSA.Thenomogram(F)isusedtoplotthechild'sheightandweight,andthepointatwhich
theyintersectistheBSAmathematicalconstantusedtocalculatethechild'sdose.(B,D,andE)
arenotusedtocalculatepediatricdosages.
Awarded0.0pointsoutof1.0002possiblepoints.
56. Indevelopingateachingplanfora5yearoldchildwithdiabetes,whichcomponentof
diabeticmanagementshouldthenurseplanforthechildtomanagefirst?
A.
Foodplanningandselection.
B.
Administeringinsulininjections.
C.
Processofglucosetesting. Correct
D.
Drawingupthecorrectinsulindose.
ID:310950724
Developmentally,a5yearoldhasthecognitiveandpsychomotorskillstouseaglucometer(C)
andtoreadthenumber(itisespeciallyhelpfulifthenursepresentsthisactivityasagame).(A,
B,andD)requiremoreadvancedcognitiveandpsychomotorskillsandhavegreaterpotential
forerrors.
Awarded1.0pointsoutof1.0possiblepoints.
57. Apreschoolagechildwhoishospitalizedforhypospadiasrepairismoststrongly
influencedbywhichbehavior?
ID:310949434
A.
Abilitytocommunicateverbally.
B.
Responsetoseparationfromfamily. Incorrect
C.
Concernforbodyintegrity. Correct
D.
Socializationwithotherchildren.
Thepreschooler'smajorstressorisconcernforhisbodyintegrity(C).Hefearsthathis"insides
willleakout."Achildundergoingsurgerytohisgenitaliaisevenmoreconcernedaboutbody
integrity.Thepreschoolerisquiteverbal,socomprehensionofthewordsheusesorhearsmay
beinaccurate,whilehisimaginationandfearsmayfantasizethereality(A).(B)isaconcernfor
allchildren,butofmostconcerntothetoddler.(D)isnotaprimeconcerninthissituation.
Awarded0.0pointsoutof1.0possiblepoints.
58. AfemaleteenageristakingoraltetracyclineHCL(AchromycinV)foracnevulgaris.What
isthemostimportantinstructionforthenursetoincludeinthisclient'steachingplan?
A.
Usesunscreenwhenlyingbythepool. Correct
B.
Cleansetheskinatleast4timesaday.
C.
Takethemedicationwithaglassofmilk.
D.
Menstrualperiodsmaybecomeirregular.
ID:310978603
PhotosensitivityisacommonsideeffectoftetracyclineHCL(AchromycinV)therapy.Severe
sunburncanoccurwithminimalsunexposureandclientsshouldbeinstructedtoavoidsunlight
andtousesunscreen(A).(BandD)arenotrelatedtotetracyclineHCL(AchromycinV)therapy.
(C)shouldbeavoidedbecausedairyproductsinterferewiththeabsorptionoftetracyclines.
Awarded1.0pointsoutof1.0possiblepoints.
59. ThenurseisassessingtheneurovascularstatusofachildinRussell'straction.Which
findingshouldthenursereporttothehealthcareprovider?
ID:310955065
A.
Palebluishcolorationofthetoes. Correct
B.
Skiniswarmanddrytothetouch.
C.
Toesarewiggleduponcommand.
D.
Capillaryrefilllessthan3seconds.
Russell'sskintractionisusedforfracturesofthefemurinyoungchildrenandadolescents
whosegrowthplatesremainopenandisappliedtothelowerlegusingmoleskinandelastic
wrapbandages,whichcancompresstheperonealnerveandarteriesthatsupplythefoot.
Assessmentofadequarecirculation,movement,andsensationofthetoesandskindistaltothe
applicationismadetoidentifycompromisedbloodflow,socyanosis(A)shouldbereported
immediately.(B,CandD)arenormalfindings.
Awarded1.0pointsoutof1.0possiblepoints.
Typeofreactiontoloudnoises. Correct
B.
Anysurgeriesontheearssincebirth.
C.
Drainagefromtheinfant'sears.
D.
Numberofearinfectionssincebirth.
Ototoxicitydiminisheshearingacuityandcausessymptomsoftinnitusandvertigoinolder
childrenwhocanexpresssubjectivesymptoms,soassessinganinfant'sreactiontoloudnoises
(A)helpstodetermineaninfant'sriskforahearingdeficitrelatedtoahistoryofthemother
takinganototoxicdrug,suchasaspirin,whilepregnant.(B,C,andD)arenotassociatedwith
exposuretoaspirininutero.
Awarded1.0pointsoutof1.0possiblepoints.
ID:311023669
61. At8a.m.theunlicensedassistivepersonnel(UAP)informsthechargenursethata
femaleadolescentclientwithacuteglomerulonephritishasabloodpressureof210/110.The4a.m.
bloodpressurereadingwas170/88.TheclientreportstotheUAPthatsheisupsetbecauseher
boyfrienddidnotvisitlastnight.Whatactionshouldthenursetakefirst?
A.
Givetheclienther9a.m.prescriptionforanoraldiureticearly.
B.
AdministerPRNprescriptionofnifedipine(Procardia)sublingually. Correct
C.
Notifythehealthcareproviderandinformthenursingsupervisoroftheclient'scondition.
D.
Attempttocalmtheclientandretakethebloodpressureinthirtyminutes. Incorrect
SublingualProcardia(B)lowersbloodpressureveryquickly,andthisshouldbedonefirst.(A)
mayalsobedone,butoraldiureticsdonotworkasrapidlyasthesublingualantihypertensive.
Whennotifyingthehealthcareprovider,thefirstthinghe/shewillwanttoknowisifthePRN
antihypertensivehasbeenadministered(C).(D)doesnotconsidertheseriousnessofthis
finding.Thenurseshouldstaywiththeclientuntilthebloodpressureisreduced.
Awarded0.0pointsoutof1.0possiblepoints.
Choking,coughing,andcyanosis. Correct
B.
Projectilevomitingandcyanosis.
C.
Apneicspellsandgrunting.
D.
Scaphoidabdomenandanorexia.
(A)includesthe"3Cs"ofesophagealatresiacausedbytheoverflowofsecretionsintothe
trachea.Projectilevomiting(B)ischaracteristicofpyloricstenosisintheinfant.Apneicspells
oftenoccurwithprematurityorsepsis,andgrunting(C)isasignofrespiratorydistress.A
scaphoidabdomen(D)ischaracteristicofdiaphragmatichernia.
Awarded1.0pointsoutof1.0possiblepoints.
63. Surgeryisbeingdelayedforaninfantwithundescendedtestes.Incollaborationwiththe
healthcareproviderandthefamily,whichprescriptionshouldthenurseanticipate?
A.
Atrialofadrenocorticotrophichormoneinjections.
B.
Frequentstimulationofthecremastericreflex.
ID:310946678
C.
Atrialofhumanchorionicgonadotrophichormone. Correct
D.
Frequentwarmbathstogentlydilatethescrotalarea. Incorrect
AtrialofHCG(humanchorionicgonadotrophichormone)(C)mayaidintesticulardescent,but
doesnotreplacesurgicalrepairfortrueundescendedtestes.Undescendedtestes
(cryptorchidism)maybefoundintheinguinalcanalduetoexaggeratedcremastericreflex.(A)
isnotindicated.Stimulationofthecremastericreflexcausesthetestestoascendratherthan
descendinthescrotum(B).(D)mayrelaxthecremastericmuscle,butmaynotcausethetestes
todescend.
Awarded0.0pointsoutof1.0possiblepoints.
Alowersensitivityreactionstoskinirritants.
B.
Athinstratumcorneumthatincreasestopicalabsorption. Correct
C.
Asmallerpercentageofmusclemass.
D.
Agreaterbodysurfaceareathatrequireslargerdosages.
Infantshaveathinouterskinlayer(stratumcorneum),sothenurseshouldmonitortheinfantfor
apromptonsetandresponsetotheapplicationoftopicalmedication(B).(A,C,andD)are
unrelatedtotopicalmedicationadministration.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310947636
65. Themotherofa4yearoldchildasksthenursewhatshecandotohelpherother
childrencopewiththeirsiblingsrepeatedhospitalizations.Whichisthebestresponsethatthenurse
shouldoffer?
A.
Informtheparentthatthechildistooyoungtovisitthehospital.
B.
Suggestthatthechildvisitagrandmotheruntilthesiblingreturnshome.
C.
Askthemotherifthechildaskswhenthesiblingwillbedischarged.
D.
Encouragethemothertohavethechildrenvisitthehospitalizedsibling. Correct
Needsofasiblingwillbebettermetwithfactualinformationandcontactwiththeillchild,so
siblingvisitationshouldbeencouraged(D).Parentsareexpertsontheirchildrenandshould
determinewhentheirchildrenareoldenoughtovisit(A)inthehospital.Separationfromfamily
andhome(B)mayintensifyfearandanxiety.Childrenmayhavedifficultyexpressingquestions
(C),sothesupportofparentsandothercaregiversareneededtohelpalleviatetheirfears.
Awarded1.0pointsoutof1.0possiblepoints.
Obtainglovesforthechild'shands.
B.
Applyfingercotsonthechild'sfingers. Incorrect
C.
Placeelbowrestraintsonthechild'sarms. Correct
D.
Applysoftrestraintstothechild'swrists.
Elbowrestraints(C)preventarmflexionandscratchingofinvolvedareas,butdonotinhibituse
ofthehandsforplayactivities.(AandB)canbeeasilyremovedbythechildandwouldrestrict
handmovement.(D)wouldbeineffectiveinpreventingthechildfromscratchingbecausethe
upperbodycouldbemovedwithinreachofrestrainedhands,andwouldalsocreatethe
greatestrestrictionofhandmovement.
Awarded0.0pointsoutof1.0possiblepoints.
67. Whenplanningthecareforachildwhohashadacleftliprepair,thenurseknowsthat
cryingshouldbeminimizedbecauseit
A.
increasessalivation.
B.
increasestherespiratoryrate.
C.
leadstovomiting.
D.
stressesthesutureline. Correct
ID:310953497
Preventionofstressonthelipsutureline(D)isessentialforoptimumhealingandthecosmetic
appearanceofacleftliprepair.Althoughcryingalsocauses(A,B,andC),theseconditionsdo
notcreateaproblemforthechildwithacleftliprepair.
Awarded1.0pointsoutof1.0possiblepoints.
Monitorthetheinfant'sweightandnumberofwetdiapersperday. Correct
B.
Increasetheinfant'sintakeperfeedingby1to2ouncesperweek. Correct
C.
Mixthedoseofprophylacticantibioticinafullbottleofformula.
D.
Allowtheinfanttorestandrefeedondemandorevery2hours. Correct
E.
Useasofternippleorincreasethesizeofthenippleopening. Correct
Correctresponsesare(A,B,D,andE).NeonateswhohaveVSDmayfatiguequicklyduring
feedingandingestinadequateamounts.Theyshouldbemonitoredforweightgainandatleast
6wetdiapersperday(A).Aonemontholdinfantshouldingest2to4ouncesofformulaper
feedingandprogresstoabout30ouncesperdayby4monthsofage(B).Duetofatigue,the
infantshouldrest,butfeedatleastevery2hourstoensureadequateintake(D).Asofter
(preemie)nippleoralargerslitinthenipple(E)helpstoreducethesuckingeffortandenergy
expenditure,thusallowingtheinfanttoingestmorewithlesseffort.Antibioticprophylaxisis
recommendedforinfantswithVSDs,butshouldnotbemixedinabottleofformula(C)because
itisdifficulttoensurethatthetotaldoseisconsumed.
Awarded0.0pointsoutof1.0possiblepoints.
69. Thenurseishavingdifficultycommunicatingwithahospitalized6yearoldchild.Which
approachbythenurseismosthelpfulinestablishingcommunication?
A.
Engagethechildthroughdrawingpictures. Correct
B.
Suggestthattheparentreadabooktothechild.
ID:310944556
C.
Providepaperandpencilforthechildtokeepadiary.
D.
Asktheparentifthechildisalwaysuncommunicative.
Drawingpictures(A)isavaluableformofnonverbalcommunication.Asthenurseandchild
lookatthedrawings,averbalstorycanbetoldthatprojectsthechild'sthinking.(B)maydistract
thechild,butdoesnotestablishcommunicationwiththenurse.(C)isusefulforanolderchild
whoisabletowrite.(D)isimportant,butengagingthechildismoreeffectiveinestablishing
communicationpatterns.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310993943
70. Duringroutinescreeningataschoolclinic,anotoscopeexaminationofachild'sear
revealsatympanicmembranethatispearlygray,slightlybulging,andnotmovable.Whatactionshould
thenursetakenext?
A.
Noactionrequired,asthisisanexpectedfindingforaschoolagedchild. Incorrect
B.
Askthechildifhe/shehashadacold,runnynose,oranyearpainlately. Correct
C.
D.
Sendanotehomeadvisingtheparentstohavethechildevaluatedbyahealthcareprovider
assoonaspossible.
Calltheparentsandhavethemtakethechildhomefromschoolfortherestoftheday.
Moreinformationisneededtointerpretthesefindings(B).Thetympanicmembraneisnormally
pearlygray,notbulging,andmoveswhentheclientblowsagainstresistanceorasmallpuffof
airisblownintotheearcanal.Sincethischild'sfindingsarenotcompletelynormal,further
assessmentofhistoryandrelatedsignsandsymptomsisindicatedforaccurateinterpretationof
thefindings.(A,C,andD)areinappropriateactionsbasedonthedataobtainedfromthe
otoscopeexamination.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310949404
71. A15yearoldgirltellstheschoolnursethatallofherfriendshavestartedtheirperiods
andshefeelsabnormalbecauseshehasnot.Whichresponseisbestforthenurseprovide?
A.
Refertheadolescenttothehealthcareproviderforapregnancyscreen.
B.
Scheduleaconferencewithherparentstorecommendhormonetherapy.
C.
Explainthatmenarchevariesandoccursbetweentheagesof12and18years. Correct
D.
Suggestthatsheusediversionstohelphernotworryaboutdelayedmenarche.
Thenurseshouldprovideafactualandreassuringexplanationthatfocusesonindividual
variationsofmenarche,whichcannormallyoccurbetween12and18yearsofage(C).(A)
doesnotaddresstheadolescent'sconcernandisjudgmental.Menarcheisinfluencedby
hereditary,generalhealth,andnutritionalstatus,so(B)isnotindicated.(D)dismissesthe
adolescent'sconcernsanddoesnotofferfactualinformation.
Awarded1.0pointsoutof1.0possiblepoints.
72. Thenurseisteachingtheparentsofa5yearoldwithcysticfibrosisaboutrespiratory
treatments.Whichstatementindicatestothenursethattheparentsunderstand?
A.
Performposturaldrainagebeforestartingaerosoltherapy.
B.
Giverespiratorytreatmentswhenthechildiscoughingalot.
C.
Administeraerosoltherapyfollowedbyposturaldrainagebeforemeals. Correct
D.
Ensurerespiratorytherapyisdonedailyduringanyrespiratoryinfection.
ID:310978647
Posturaldrainageforachildwithcysticfibrosisismosteffectivewhenperformedafter
nebulizationandbeforemeals(C)oratleast1houraftereatingtopreventnauseaand
vomiting.Posturaldrainageusesgravitytopromotemucousremovalafternebulization(A)
treatmentswhichopentheairways.Pulmonarytoiletingorrespiratorytreatmentsshouldbe
given3to4timesdaily,notepisodically(BandD).
Awarded1.0pointsoutof1.0possiblepoints.
73. Thenurseobservesa4yearoldboyinadaycaresetting.Whichbehaviorwouldthe
nurseconsidernormalforthischild?
A.
Hasatempertantrumwhentoldhemustsharehistoys. Incorrect
ID:311028909
B.
Playsbyhimselfmostoftheday.
C.
Demonstratesaggressivenessbyboastingwhentellingastory. Correct
D.
Beginstocryandisfearfulwhenseparatedfromhisparents.
Fouryearoldchildrenareaggressiveintheirbehaviorandenjoy"taletelling"(C).Behaviorsin
(AandD)aretypicaloftoddlers.Theplayofapreschooleriscooperative,soplayingalone(B)
isnottypical.
Awarded0.0pointsoutof1.0possiblepoints.
74. PreoperativenursingcareforachildwithWilms'tumorshouldincludewhich
intervention?
A.
Gentlypercusstheabdomenforevidenceoftrappedair.
B.
Observetheabdomenforanynoticeablediscolorations. Incorrect
C.
Applycoldcompressestotheabdomentoreduceedema.
D.
Putasignonthebedreading,"DONOTPALPATEABDOMEN." Correct
ID:311008997
Preventionofabdominalpalpation(D)minimizestheriskofrupturingtheencapsulatedtumor
andsubsequentmetastasis.(A)isunnecessary,andthisactioncouldtraumatizethetumorin
thesamemanneraspalpation.(BandC)areincorrectsincetheabdomenisnotdiscoloredand
coldcompressesarenotindicated.
Awarded0.0pointsoutof1.0possiblepoints.
ID:310944586
75. Thenurseisdevelopingaplanofcarefora3yearoldwhoisscheduledforacardiac
catheterization.Toassistindecreasinganxietyforthechildonthedayoftheprocedure,which
interventionisbestforthenursetoimplement?
A.
B.
C.
Reassuretheparentsthat3yearoldsarecooperativeandthereforearelesslikelytobe
anxious.
Obtainavideofilmofacardiaccatheterizationtoshowtothechildpriortotheprocedure.
Givethechildarideonagurneytovisitthecardiaccatheterizationlabandmeetanurse
whoworksthere. Correct
D.
Obtainacardiaccatheteranddemonstratetheprocedurebypretendingtoputthecatheterin
adollorstuffedanimal.
Familiarizingthechildandmotherwiththedepartment(C)willhelpdecreaseanxietyofthechild
andmother(whomayhavemoreanxietythanthechild).Threeisadifficultagetoundergoa
procedurethatrequirescooperation.Restraintsandpossiblysedationmayberequired(A).At
three,thechildistooyoungtounderstandwhythismustbedone,and(B)isnotindicated.(D)
isalsonotindicatedbecauseitislikelytobeinterpretedaspainful.
Awarded1.0pointsoutof1.0possiblepoints.
76. A3montholdinfantdevelopsoralthrush.Whichpharmacologicagentshouldthenurse
plantoadministerfortreatmentofthisdisorder?
A.
Nystatin(Mycostatin). Correct
B.
Nitrofurantoin(Macrodantin).
C.
Norfloxacin(Noroxin). Incorrect
D.
Neomycinsulfate(Mycifradin).
ID:310972743
Nystatin(Mycostatin)(A)isanantifungaldrugthatiseffectiveintreatingthrush,anoralfungal
infection.(B,C,andD)arenotindicatedforthetreatmentoforalthrush.
Awarded0.0pointsoutof1.0possiblepoints.
ID:311013613
77. Thenurseisassigningcarefora4yearoldchildwithotitismediaandisconcerned
aboutthechild'sincreasingtemperatureoverthepast24hours.Whenplanningcareforthischild,itis
importantforthenursetoconsiderthat
A.
onlyanRNshouldbeassignedtomonitorthischild'stemperature.
B.
atympanicmeasurementoftemperaturewillprovidethemostaccuratereading. Correct
C.
thelicensedpracticalnurseshouldbeinstructedtoobtainrectaltemperaturesonthischild.
D.
thehealthcareprovidershouldbeaskedtoprescribethemethodformeasurementofthe
child'stemperatures.
(B)Atympanicmembranesensorisanexcellentsitebecauseboththeeardrumand
hypothalamus(temperatureregulatingcenter)areperfusedbythesamecirculation.Thesensor
isunaffectedbycerumenandthepresenceofsuppurativeorunsuppurativeotitismediadoes
noteffectmeasurement.RULEOFTHUMB:formanagementsterileproceduresshouldbe
assignedtolicensedpersonnel.ManagementskillswillbetestedontheNCLEX!AnRNisnot
required(A).Rectaltemperaturemeasurement(C)islessaccuratebecauseofthepossibilityof
stoolintherectum.(D)isunnecessary.
Awarded1.0pointsoutof1.0possiblepoints.
78. Whichbehaviorwouldthenurseexpecta2yearoldchildtoexhibit?
A.
Buildahousewithblocks.
B.
Rideatricycle.
C.
Displaypossessivenessoftoys. Correct
D.
Lookatapicturebookfor15minutes.
ID:311018755
2yearoldchildrenareegocentricandunabletosharewithotherchildren.(A,B,andD)are
behaviorsofapreschooler.
Awarded1.0pointsoutof1.0possiblepoints.
79. Achildisrescuedfromaburninghouseandbroughttotheemergencyroomwithpartial
thicknessburnsonthefaceandchest.Whichactionshouldthenurseimplementedfirst?
A.
Insertanindwellingurinarycatheter.
B.
AdministerIVpainmedication.
C.
Collectbloodspecimenforlaboratorystudies.
D.
Assessthechild'srespiratorystatus. Correct
ID:311041554
Assessingtheairwayandtherespiratorystatusisthehighestpriority(D)sinceburnstotheface
andchestplacethechildatriskforsmokeinhalationinjuryandcompromisedairway.(A,B,and
C)areimplementedafter(D).
Awarded1.0pointsoutof1.0possiblepoints.
ID:310957405
80. ThemotherofapreschoolagedchildasksthenurseifitisallrighttoadministerPepto
Bismoltohersonwhenhe"hasatummyache."Afterremindingthemothertocheckthelabelofall
overthecounterdrugsforthepresenceofaspirin,whichinstructionshouldthenurseincludewhen
replyingtothismother'squestion?
A.
Ifthechild'stonguedarkens,discontinuethePeptoBismolimmediately.
B.
Donotgiveifthechildhaschickenpox,theflu,oranyotherviralillness. Correct
C.
AvoidtheuseofPeptoBismoluntilthechildisatleast16yearsold. Incorrect
D.
PeptoBismolmaycauseareboundhyperacidity,worseningthe"tummyache."
PeptoBismolcontainsaspirinandthereisthepotentialofReye'ssyndrome(B).(A)isa
commoneffectofPeptoBismolanddoesnotwarrantdiscontinuation.PeptoBismolcanbe
usedbychildren(C).PeptoBismoldoesnotcausereboundhyperacidity(D),whichisa
complicationofantacidscontainingcalcium.
Awarded0.0pointsoutof1.0possiblepoints.
81. Asixmontholdreturnsfromsurgerywithelbowrestraintsinplace.Whatnursingcare
shouldbeincludedwhencaringforanyrestrainedchild?
A.
Keeprestraintsonatalltimes.
B.
Removerestraintsoneatatimeandproviderangeofmotionexercises. Correct
C.
Removeallrestraintssimultaneouslyandprovideplayactivities.
D.
Renewthehealthcareprovider'sprescriptionforrestraintsevery72hours.
ID:311028901
Removingrestraintsoneatatime(B)issaferthanremovingallofthematonce(C).Thechild
needstoexerciseandshouldnotbekeptinrestraintsatalltimes(A).Therenewalofthe
healthcareprovider'sprescriptionvarieswithhospitals(D),anditdoesnotreallyanswerthe
question.
Awarded1.0pointsoutof1.0possiblepoints.
ID:310945250
82. Thenurseassigningcarefora5yearoldchildwithotitismediaisconcernedaboutthe
child'sincreasingtemperatureoverthepast24hours.Whichstatementisaccurateandshouldbe
consideredwhenplanningcarefortheremainderoftheshift?
A.
AnRNshouldbeassignedtotaketemperaturesfrequently.
B.
Tympanicandoraltemperaturesareequallyaccurate. Correct
C.
ThePNshouldtakerectaltemperaturesonthischild.
D.
Thepediatricianshoulddecidehowtoassessthetemperature.
Atympanicmembranesensorapproximatescoretemperaturesbecausethehypothalamusand
eardrumareperfusedbythesamecirculation.Tympanicreadingsobtainedusingproper
techniquecorrelatedmoderatelytostronglywithoraltemperaturesinrecentresearchstudies
(B).Thesensorisunaffectedbycerumenorthepresenceofsuppurativeorunsuppurativeotitis
media.AnRNisnotrequiredtotakethechild'stemperature,butmustassessreadingsreceived
fromassistivepersonnel(A).Althoughrectalreadingsarehighlyaccurate(C),suchaninvasive
procedureisunnecessary.(D)isnotrequired.
Awarded1.0pointsoutof1.0possiblepoints.
83. Thenurseisgivingaliquidironpreparationtoa3yearoldchild.Whichtechniqueshould
thenurseimplementtoengagethechild'scooperation?
A.
Useacolorfulstraw. Correct
B.
Mixthemedicationinwater.
C.
Administerthemedicationusinganoralsyringe.
D.
Askthepharmacytoprovideanenterictablet.
ID:311041546
Aliquidironpreparationadministeredthroughastrawmayhelpthechildtoacceptthe
medicationsinceyoungchildrenconsiderdrinkingfromacolorfulstrawfun(A).(B)maycause
stainingofthechild'steeth.(C)isoftenusedifthechildisuncooperative.(D)isineffectiveand
shouldberequestedfromthehealthcareprovider.
Awarded1.0pointsoutof1.0possiblepoints.
84. Whichactionbythenurseismosthelpfulincommunicatingwithapreschoolagedchild?
ID:310972767
A.
Speakclearlyanddirectlytothechild.
B.
Useadolltoplayandcommunicate. Correct
C.
Approachwhenaparentisnotpresent.
D.
Playaboardgamewiththechild.
Communicatingthroughplaywithadoll(B)orothertoygivestimeforthechildtofeel
comfortablewithastranger.(A)mayfrightensomechildrenandisusuallynotaseffectiveas
(B).Toprovidesecurityandcomfort,preschoolagedchildrenshouldbeapproachedwhena
parentispresent,not(C).(D)istooadvancedforapreschooler.