QUESTIONS AND
CORRECT DETAILED
ANSWERS
a nurse is planning care for a child who has severe diarrhea. which of the following actions is the nurse
priority? - Correct Answer - Correct Answer: Assess fluid balance
A nurse is caring for a toddler who's parent states that the child has a mass in his abdominal area and his
urine is a pink color. Which of the following actions is the nurse's priority? - Correct Answer - Correct
Answer: Instruct the parent to avoid pressing on the abdominal area
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the
nurse's priority? - Correct Answer - Correct Answer: Check the Childs weight daily
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following
is the nurse's priority? - Correct Answer - Correct Answer: Administer antibiotics when available
A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for
suicide? - Correct Answer - Correct Answer: Active psychiatric disorder (Mark, mental problems,
patients mind is unstable)
A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should
expect which of the following findings? - Correct Answer - Correct Answer: Tugging on the affected ear
lobe
A nurse is reinforcing reaching with a parent of a 1 month old infant who is to undergo the initial surgery
to treat Hirschsprung's disease (a ganglionic megacolon, part of the colon isn't connected to the nerves
or not functioning, so there will be an increase size of the colon and stool gets stuck in there). Which of
the following statements should indicate to the nurse that the parent understanding the goal of
, surgery? - Correct Answer - Correct Answer: "I'm glad that the ostomy is only temporary " (1st there
going to cut the nonfunctioning of the colon, and then apply temporary colostomy, after a couple of
months they will suture it together)
A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of
the following actions should the nurse take? - Correct Answer - Correct Answer: Apply an antibiotic
ointment to the suture site
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the
following statements by the parent indicates an understanding of the teaching? - Correct Answer -
Correct Answer: "I will make sure my child washes her hands before eating"
A nurse working at a clinic speaks on the telephone with a parent of a 2-monthold infant. The parent
tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the
following response by the nurse is appropriate? - Correct Answer - Correct Answer: "Bring your infant
into the clinic today to be seen"
A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a
ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority .
(causes icp hydrocephalus) - Correct Answer - Correct Answer: lethargy (high pitched cry, respiratory
changes, bradycardia, wide pulse pressure, irritability
a nurse is caring for a child following an open reduction and internal fixation of a fractured femur and
application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following
actions should the nurse take first? - Correct Answer - Correct Answer: Perform neurovascular checks
of the affected extremity (check for infection, color, capillary refill, redness)
A nurse is an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin.
Which of the following substances should the nurse administer to the toddler? - Correct Answer -
Correct Answer: Activated charcoal (can work with toxin, poison. Given through ng tube absorbs toxins)
A nurse is caring for a 3 year old client who has persistent otitis media. To help identify contributing
factors, the nurse should ask the parents which of the following questions? - Correct Answer - Correct
Answer: Does anyone smoke in the same house as your daughter? (smoking can cause irritation, cause
mucus in respiratory and causes otitis media?) (otitis media is purulent color)