ANSWERS 2023-2024
A nurse is completing an admission assessment on an adolescent child who is a vegetarian. He eats milk
products but does not like beans. Which of the following items should the nurse suggest the client order
for lunch to provide nutrients most likely to be lacking in his diet? -ANS-Peanut Butter and Jelly
Sandwich
A nurse is caring for a 1-month old infant who weighs 3540 g and is prescribed a dose of cefazolin
50mg/kg IV bolus TID. How many mg should the nurse administer per dose? -ANS-
A nurse is preforming a pre-college assessment on an adolescent. Which of the following immunizations
should the nurse anticipate administering? -ANS-Meningococcal polysaccharide vaccine
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect? -ANS-Nocturia at night
A nurse is caring for a client who has active TB and is to be started on IV rifampin therapy. The nurse
should instruct the client that this medication can cause which of the following adverse effects? -ANS-
Body sections turning a red orange color
A nurse is caring for a 6-week-old infant who as a pyloric stenosis. Which of the following manifestations
should the nurse expect? -ANS-Projectile vomiting
A nurse receives a call from a parent of a child who has von Willebrand disease and has having a
nosebleed. Which of the following instructions should the nurse give to the parents? -ANS-"Have your
child sit with her head tilted forward and hold pressure on her nose for 10 minutes."
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse
expect? -ANS-Pain
A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is
scheduled for surgery in the morning. Which of the following actions should the nurse include in the
demonstration? -ANS-Place her hands on the sides of her rib cage
, A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the
nurse expect? (select all that apply). -ANS--Hypotension
-Weak pulses
-Murmur
A nurse is planning care for a client who has idiopathic thrombocytopenic purpur (ITP). Which of the
following manifestations is the most appropriate for the nurse to monitor? -ANS-Bleeding
A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial
surgery. Which of the following statements indicates an understanding of the teaching? -ANS-I'm glad
that my child's ostomy is only temporary
A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the
condition. Which of the following statements by the parents indicated an understanding of the
teaching? -ANS-All recently used clothing, bedding, and towels must be washed in hot water.
A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse
should instruct that the transition to whole milk can occur at which of the following ages? -ANS-12
months
A nurse is assessing a 6-month old patient at a well-child visit. Which of the following findings should the
nurse expect? -ANS-Closed posterior fontanel
A nurse is caring for a 2-year old child who has seizures and is receiving phenytoin in suspension form.
Which of the following actions should the nurse take before administering each dose? -ANS-Shake the
container vigorously.
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring
urinary tract infections. Which of the following actions should the nurse include in the client's plan of
care? -ANS-Obtain a order for an in and out catheter
A nurse is planning care for a child who has suspected epiglottis. Which of the following actions should
the nurse take? -ANS-Place the child on droplet precautions