1. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV
bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After
discontinuing the medication infusion, which of the following medications should the
nurse administer first?
Correct Ans- epinephrine
2. A nurse is teaching the parent of an infant about ways to prevent sudden infant death
syndrome (SIDS). Which of the following instructions should the nurse include?
Correct Ans- give the infant a pacifier
3. A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the
following findings should the nurse expect? (Select all that apply.)
Correct Ans- -Ankle clonus-Exaggerated stretch reflexes-Contractures
4. The nurse is providing discharge teaching to the parent of a child who is 1 week
postoperative following a cleft palate repair. For which of the following members of the
inter professional team should the nurse initiate a referral?
Correct Ans- speech therapist
5. A nurse is creating a plan of care for an infant who has an epidural hematoma from a
head injury. Which of the following interventions should the nurse include in the plan?
Correct Ans- Implement seizure precautions for the infant.An infant who has an epidural
hematoma is at great risk for seizure activity. Therefore, the nurse should implement
seizure precautions for the child.
6. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions
should the nurse take?
Correct Ans- apply a topical analgesic cream to the site 1 hr prior to procedure
7. A nurse is providing teaching to the parent of a school-age child who has a new
prescription for oral nystatin for the treatment of oral candidiasis. Which of the following
instructions should the nurse include?
Correct Ans- "Shake the medication prior to administration."The nurse should instruct the
parent to shake the medication prior to administration to disperse the medication evenly
within the suspension.
, 8. A nurse in an emergency department is performing an admission assessment on a 2 week-
old male newborn. Which of the following findings is the priority for the nurse to report
to the provider?
Correct Ans- substernal retractions
9. A nurse is receiving change-of-shift report on four children. Which of the following
children should the nurse see first?
Correct Ans- A school-age child who has sickle cell anemia and reports decreased vision
in the left eye.When using the urgent vs. nonurgent approach to client care, the nurse
should determine the priority finding is a report of decreased vision in the left eye. This
finding indicates that the child is experiencing a vaso-occlusive crisis and should be
reported to the provider immediately. Therefore, the nurse should see this child first.
10. A nurse is assessing a school-age child who has meningitis. Which of the following
findings is the priority for the nurse to report to the provider?
Correct Ans- Petechiae on the lower extremitiesThe presence of a petechial or purpuric
rash on a child who is ill can indicate the presence of meningococcemia. This type of rash
indicates the greatest risk of serious rapid complications from sepsis and should be
reported immediately to the provider.
11. A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following
manifestations should the nurse report to the provider?
Correct Ans- Respiratory rate 45/minThe nurse should identify that a respiratory rate of
45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and
can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse
should report this finding to the provider.
12. A nurse is reviewing the laboratory report of a school-age child who is experiencing
fatigue. Which of the following findings should the nurse recognize as an indication of
anemia?
Correct Ans- Hematocrit 28%The nurse should recognize that this hematocrit level is
below the expected reference range of 32% to 44% for a school-age child. The child can
exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased
oxygen-carrying capacity.
13. A nurse is planning care for a school-age child who is in the oliguric phase of acute
kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following
interventions should the nurse include in the plan?
Correct Ans- Initiate seizure precautions for the child.A sodium level of 129 mEq/L
indicates hyponatremia and places the child at increased risk for neurological deficits and