A 3 year-old patient presents following frequent emesis and diarrhea over the past 12 hours. Which of the
following assessment findings indicate that the patient' body is compensating for the fluid loss?
A.Increased diastolic blood pressure
B.Bounding peripheral pulses
C.Prolonged capillary refill
D.Increased urine output
You are discharging a patient home who has a history of depression. Discharge teaching should include which of
the following?
A.Discussing the importance of stopping all current psychiatric medications.
B.Providing the family a list of behavioral health facilities to call for follow-up.
C.Explaining that the family should not call authorities for escalations in the patient's behavior.
D.Ensuring all firearms in the home are locked up with no access available by the patient.
A child with an electrical injury is seen 1 hour post event. Which of the following specimen samples would
provide visual information regarding a potential complication of this injury?
A.Serum
B.Urine
C.Stool
D.Sputum
,A 4-year-old patient is being assessed for a foreign body in the nose. The child is awake and alert and watching a
video on the caregivers phone. Vitals include HR of 110 beats/minute, RR of 26 breaths per minute, BP of 138/90
mm Hg, and T of 37.3oC (99.3oF) orally. Which of the following interventions should the nurse perform next?
A.Check the size of the blood pressure cuff
B.Recheck the temperature rectally
C.Recheck the blood pressure on the other arm
D.Place the patient on cardiac and respiratory monitors
A 10-year-old playing baseball is hit in the chest with a ball. He immediately demonstrates loss of consciousness
with no pulses. Which of the following is the priority intervention?
A.Utilize AED/defibrillator
B.Prepare for needle decompression
C.Administer intravenous epinephrine
D.Intubate with endotracheal tube
The triage nurse is assessing a 14 year old male who was brought in by ambulance. The patient reports he was
playing his video games at home when he had a sudden onset of groin pain that was so severe he became
nauseated and vomited. Further assessment reveals a swollen scrotum. What is the priority intervention for this
patient?
A.Obtaining a sterile urine sample
B.Initiating intravenous access
C.Preparing the patient for ultrasound
D.Scanning the patient's bladder
,A caregiver reports their one-month-old has had a yellowish color to their eyes and skin over the last two weeks.
If left untreated, which body system can this affect?
A.Integumentary
B.Renal
C.Gastrointestinal
D.Neurological
An infant presents to the emergency department with difficulty breathing. The patient is pale and respirations
appear rapid and shallow. Which location on the torso is the most effective site for assessing bilateral breath
sounds?
A.Bilateral posterior back
B.Over the epigastrium
C.Bilateral midaxillary
D.Bilateral anterior chest
A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after
eating lunch. Which of the following is the priority intervention?
A.Intramuscular epinephrine
B.Inhaled albuterol
C.Oral diphenhydramine
D.Intravenous ondansetron
, A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares
over the past 6 hours. Which of the following foreign bodies is the most likely etiology?
A.Magnet
B.Button battery
C.Dried bean
D.Fishing weight
Caregivers state an 18-month-old child had a harsh, barky cough, low-grade fever, and irritability throughout the
night. On assessment this morning, the child appears alert, is interactive, their present cough is quiet, and their
temperature is 98.8°F (37.1°C) axillary. Which of the following diagnoses is the highest probablity for this child?
A.Asthma
B.Croup
C.Epiglottitis
D.Pneumonia
A 12-year-old female patient arrives awake and alert with an acute onset of abdominal pain on the right side,
nausea, vomiting, and vaginal spotting. On palpation, the pain is localized to the right side and there is tenderness
to the breasts. Which of the following laboratory tests is the priority for this patient?
A.Human chorionic gonadotropin
B.Complete blood count
C.Vaginal cultures
D.Bedside glucose level
following assessment findings indicate that the patient' body is compensating for the fluid loss?
A.Increased diastolic blood pressure
B.Bounding peripheral pulses
C.Prolonged capillary refill
D.Increased urine output
You are discharging a patient home who has a history of depression. Discharge teaching should include which of
the following?
A.Discussing the importance of stopping all current psychiatric medications.
B.Providing the family a list of behavioral health facilities to call for follow-up.
C.Explaining that the family should not call authorities for escalations in the patient's behavior.
D.Ensuring all firearms in the home are locked up with no access available by the patient.
A child with an electrical injury is seen 1 hour post event. Which of the following specimen samples would
provide visual information regarding a potential complication of this injury?
A.Serum
B.Urine
C.Stool
D.Sputum
,A 4-year-old patient is being assessed for a foreign body in the nose. The child is awake and alert and watching a
video on the caregivers phone. Vitals include HR of 110 beats/minute, RR of 26 breaths per minute, BP of 138/90
mm Hg, and T of 37.3oC (99.3oF) orally. Which of the following interventions should the nurse perform next?
A.Check the size of the blood pressure cuff
B.Recheck the temperature rectally
C.Recheck the blood pressure on the other arm
D.Place the patient on cardiac and respiratory monitors
A 10-year-old playing baseball is hit in the chest with a ball. He immediately demonstrates loss of consciousness
with no pulses. Which of the following is the priority intervention?
A.Utilize AED/defibrillator
B.Prepare for needle decompression
C.Administer intravenous epinephrine
D.Intubate with endotracheal tube
The triage nurse is assessing a 14 year old male who was brought in by ambulance. The patient reports he was
playing his video games at home when he had a sudden onset of groin pain that was so severe he became
nauseated and vomited. Further assessment reveals a swollen scrotum. What is the priority intervention for this
patient?
A.Obtaining a sterile urine sample
B.Initiating intravenous access
C.Preparing the patient for ultrasound
D.Scanning the patient's bladder
,A caregiver reports their one-month-old has had a yellowish color to their eyes and skin over the last two weeks.
If left untreated, which body system can this affect?
A.Integumentary
B.Renal
C.Gastrointestinal
D.Neurological
An infant presents to the emergency department with difficulty breathing. The patient is pale and respirations
appear rapid and shallow. Which location on the torso is the most effective site for assessing bilateral breath
sounds?
A.Bilateral posterior back
B.Over the epigastrium
C.Bilateral midaxillary
D.Bilateral anterior chest
A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after
eating lunch. Which of the following is the priority intervention?
A.Intramuscular epinephrine
B.Inhaled albuterol
C.Oral diphenhydramine
D.Intravenous ondansetron
, A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares
over the past 6 hours. Which of the following foreign bodies is the most likely etiology?
A.Magnet
B.Button battery
C.Dried bean
D.Fishing weight
Caregivers state an 18-month-old child had a harsh, barky cough, low-grade fever, and irritability throughout the
night. On assessment this morning, the child appears alert, is interactive, their present cough is quiet, and their
temperature is 98.8°F (37.1°C) axillary. Which of the following diagnoses is the highest probablity for this child?
A.Asthma
B.Croup
C.Epiglottitis
D.Pneumonia
A 12-year-old female patient arrives awake and alert with an acute onset of abdominal pain on the right side,
nausea, vomiting, and vaginal spotting. On palpation, the pain is localized to the right side and there is tenderness
to the breasts. Which of the following laboratory tests is the priority for this patient?
A.Human chorionic gonadotropin
B.Complete blood count
C.Vaginal cultures
D.Bedside glucose level
