Correct Answers Latest Update
What is the recommended serving size of vegetables for a toddler?
A. 1 tablespoon.
B. 1 teaspoon.
C. 1/2 teaspoon.
D. 1/2 tablespoon. - Correct Answer a
The nurse is providing emergency care for an unconscious child who presents with a
head injury sustained in a fall. Which is the highest nursing priority?
a. Establish an airway.
b. Assess neurological status.
c. Stabilize the spine.
d. Obtain vital signs. - Correct Answer a
His vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and
Respirations 24. The child's pedal pulses are present with a volume of +1, and no
edema is observed. What action should the nurse implement first?
a. Insert an indwelling urinary catheter.
b. Start an IV infusion of normal saline.
c. Send a specimen to the lab for urinalysis.
d. Document the child's vital signs and pulses. - Correct Answer b
The nurse is assessing a 2-year-old child. What behavior indicates that the child's
language development is within normal limits?
A. Is able to name four colors.
,b. Can count five blocks.
C. Is capable of making a three word sentence.
d. Half of child's speech is understandable. - Correct Answer c
At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a
female adolescent client with acute glomerulonephritis has a blood pressure of 210/110.
The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is
upset because her boyfriend did not visit last night. What action should the nurse take
first?
a. Give the client her 9 a.m. prescription for an oral diuretic early.
b. Administer PRN prescription of nifedipine (Procardia) sublingually.
c. Notify the healthcare provider and inform the nursing supervisor of the client's
condition.
d. Attempt to calm the client and retake the blood pressure in thirty minutes. - Correct
Answer b
During administration of a blood transfusion, a child complains of chills, headache, and
nausea. Which action should the nurse implement?
a. Start another IV of dextrose solution and stay with the child.
b. Continue the transfusion and monitor the child's vital signs.
c. Stop the infusion immediately and notify the healthcare provider.
d. Slow the transfusion and assess for cessation of symptoms. - Correct Answer c
The nurse is preparing a health teaching program for parents of toddlers and
preschoolers and plans to include information about prevention of accidental
poisonings. It is most important for the nurse to include which instruction?
a. Tell children they should not taste anything but food.
b. Store all toxic agents and medicines in locked cabinets.
c. Provide special play areas in the house and restrict play in other areas.
d. Punish children if they open cabinets that contain household chemicals. - Correct
Answer b
,What preoperative nursing intervention should be included in the plan of care for an
infant with pyloric stenosis?
a. Monitor for signs of metabolic acidosis.
b. Estimate the quantity of diarrhea stools.
c. Place in a supine position after feeding.
d. Observe for projectile vomiting. - Correct Answer d
Which measurements should be used to accurately calculate a pediatric medication
dosage? Select all that apply.
a. Child's height and weight.
b. Adult dosage of medication.
c. Body surface area of child.
d. Average adult's body surface area.
e. Average pediatric dosage of medication.
f. Monogram determined mathematical constant. - Correct Answer a, c, d
The nurse is assessing the neurovascular status of a child in Russell's traction. Which
finding should the nurse report to the healthcare provider?
a. Pale bluish coloration of the toes.
b. Skin is warm and dry to the touch.
c. Toes are wiggled upon command.
d. Capillary refill less than 3 seconds. - Correct Answer a
The mother of a preschool-aged child asks the nurse if it is all right to administer
bismuth subsalicylate (Pepco Bicol, Bismylate) to her son when he "has a tummy ache."
After reminding the mother to check the label of all over-the-counter drugs for the
presence of aspirin, which instruction should the nurse include when replying to this
mother's question?
a. If the child's tongue darkens, discontinue the Pepco Bicol immediately.
b. Do not give if the child has chickenpox, the flu, or any other viral illness.
, c. Avoid the use of Pepco Bicol until the child is at least 16 years old.
D/ Pepco Bicol may cause rebound hyperacidity, worsening the "tummy ache." -
Correct Answer b
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He
is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority
for this infant?
a. Give small, frequent feedings of fluids.
b. Accurately chart observations regarding breath sounds.
c. Have a bulb syringe readily available to remove secretions.
d. Encourage older siblings to visit. - Correct Answer c
The nurse is assessing a two-month-old in preparation for surgery for coarctation of the
aorta repair. Which best describes the pathophysiology of coarctation of the aorta?
a. Cyanotic defect, increased pulmonary blood flow.
b. Cyanotic defect, obstructed blood flow from ventricles.
c. Cyanotic defect, obstructed blood flow from ventricles.
d. Cyanotic defect decreased pulmonary blood flow. - Correct Answer c
The emergency department nurse is assessing a three-month-old infant suspected to
be a victim of "shaken baby syndrome". Which type of intracranial hemorrhage is
caused by tearing of a meningeal artery that causes an inward expansion of blood from
the inner surface of the skull?
a. Subarachnoid.
b. Epidural.
c. Subdural.
d. Intracerebral. - Correct Answer b
The nurse recognizes signs that a 9-month-old toddler may be living in an abusive
home. Which action is the priority for the nurse?
a. Encourage the child to speak freely.
b. Report the suspected abuse to local authorities.