2 year old is admitted to the hospital with possible encephalitis, and a lumbar puncture
is scheduled. Which information should the nurse provide this child concerning the
procedure?
A. Describe the side-lying, knees to chest position that must be assumed during
theprocedure.
B. Tell the child to expect loud clicking noises during the procedure that may be slightly
annoying.
C. Reassure the child that there will be no restrictions on activity after the procedure is
completed.
D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours
after the procedure. - Answer-a
/.22. The HR for a 3 year old with a congenital heart defect has steadily decreased over
the last few hours, now it's 76 bpm, the previous reading 4 hours ago was 110 bpm.
Which additional finding should be reported immediately to a healthcare provider?
A. Oxygen saturation 94%.
B. RR of 25 breaths/minute.
C. Urine output 20 mL/hr.
D. BP 70/40. - Answer-d
/.7 years old is admitted to the hospital with persistent vomiting, and a nasogastric tube
attached to low intermittent suction is applied. Which finding is most important for the
nurse to report to the healthcare provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mg/dL.
D. Serum pH of 7.45. - Answer-c
,/.A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When
teaching the parents, which intervention should the nurse emphasize?
a. Encouraging high-calorie snacks to prevent weight loss
b. Keeping the toddler wrapped in blankets to prevent shivering
c. Giving small amounts of clear liquids frequently to prevent dehydration
d. Using cool-water baths to prevent the toddler's fever from increasing further -
Answer-c
/.A 16 y/o female student with a history of asthma controlled with both an oral
antihistamine and an albuterol (Provenfil) metere-dose inhaler (MDI) comes to the
school nurse. The student complains that she cannot sleep at night, feels shaky and her
heart feels like it is "beating a mile per minute" Which information is most important for
the nurse to obtain?
a. When she last took the antihistamine
b. When her last Asthma attack occurred
c. Duration of most asthmas attacks
d. How often the MDI is used daily - Answer-d
/.A 16 year old male client who has been treated in the past for a seizure disorder is
admitted to the hospital. Immediately after admission he begins to have a grand mal
seizure. Which action should the nurse take?
a. Obtain assistance in holding him to prevent injury
b. Observe him carefully
c. Call a CODE
d. Place a padded tongue blade between the teeth - Answer-b
/.A 3 year old boy in a daycare facility scratches his head frequently and the nurse
confirms the presence if head lice. The nurse washes the child's hair with permethrin
(Nix) shampoo and call his parents. What instructions should the nurse provide to the
parents about treatment of head lice?
A. Wash the child's bed linens and clothing In hot soapy water
B. Dispose of the child's brushes, comb's and other hair accessories
, C. Rewash the child's hair following a 24 hour isolation period
D. Take the child to a hair salon for a shampoo and shorter haircut - Answer-a
/.A 3 year old with HIV infection is staying with a foster family who is caring for 3 other
foster children in their home. When one of the children acquires pertussis, the foster
mother calls the clinic and asks the nurse what she should do. Which action should the
nurse take first?
A. Remove the child who has HIV from the foster home
B. Report the exposure of the child with HIV to the health department
C. Place the child who has HIV in reverse isolation
D. Review the immunization documentation of the child who has HIV - Answer-d
/.A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the
best way for the nurse to evaluate fluid retention or loss?
a. Measuring the abdominal girth daily
b. Having the child urinate in a bedpan
c. Testing the child's urine for proteinuria
d. Weighing the child at the same time each day - Answer-d
/.A 4 month-old girl is brought to the clinic by her mother because she has had a cold for
2 o 3 days and woke up this morning with a hacking cough and difficulty breathing.
Which additional assessment finding should alert the nurse that the child is in acute
respiratory distress?
a. Bilateral bronchial breath sounds
b. Diaphragmatic respiration
c. A resting respiratory rate of 35 breathe per minute
d. flaring of the nares - Answer-d
/.A 6 year old who has asthma is demonstrating a prolonged expiratory phase and
wheezing and has a35% of personal best peak expiratory flow rate (PEFR) based on
these finding, actions should the nurse take first?
is scheduled. Which information should the nurse provide this child concerning the
procedure?
A. Describe the side-lying, knees to chest position that must be assumed during
theprocedure.
B. Tell the child to expect loud clicking noises during the procedure that may be slightly
annoying.
C. Reassure the child that there will be no restrictions on activity after the procedure is
completed.
D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours
after the procedure. - Answer-a
/.22. The HR for a 3 year old with a congenital heart defect has steadily decreased over
the last few hours, now it's 76 bpm, the previous reading 4 hours ago was 110 bpm.
Which additional finding should be reported immediately to a healthcare provider?
A. Oxygen saturation 94%.
B. RR of 25 breaths/minute.
C. Urine output 20 mL/hr.
D. BP 70/40. - Answer-d
/.7 years old is admitted to the hospital with persistent vomiting, and a nasogastric tube
attached to low intermittent suction is applied. Which finding is most important for the
nurse to report to the healthcare provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mg/dL.
D. Serum pH of 7.45. - Answer-c
,/.A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When
teaching the parents, which intervention should the nurse emphasize?
a. Encouraging high-calorie snacks to prevent weight loss
b. Keeping the toddler wrapped in blankets to prevent shivering
c. Giving small amounts of clear liquids frequently to prevent dehydration
d. Using cool-water baths to prevent the toddler's fever from increasing further -
Answer-c
/.A 16 y/o female student with a history of asthma controlled with both an oral
antihistamine and an albuterol (Provenfil) metere-dose inhaler (MDI) comes to the
school nurse. The student complains that she cannot sleep at night, feels shaky and her
heart feels like it is "beating a mile per minute" Which information is most important for
the nurse to obtain?
a. When she last took the antihistamine
b. When her last Asthma attack occurred
c. Duration of most asthmas attacks
d. How often the MDI is used daily - Answer-d
/.A 16 year old male client who has been treated in the past for a seizure disorder is
admitted to the hospital. Immediately after admission he begins to have a grand mal
seizure. Which action should the nurse take?
a. Obtain assistance in holding him to prevent injury
b. Observe him carefully
c. Call a CODE
d. Place a padded tongue blade between the teeth - Answer-b
/.A 3 year old boy in a daycare facility scratches his head frequently and the nurse
confirms the presence if head lice. The nurse washes the child's hair with permethrin
(Nix) shampoo and call his parents. What instructions should the nurse provide to the
parents about treatment of head lice?
A. Wash the child's bed linens and clothing In hot soapy water
B. Dispose of the child's brushes, comb's and other hair accessories
, C. Rewash the child's hair following a 24 hour isolation period
D. Take the child to a hair salon for a shampoo and shorter haircut - Answer-a
/.A 3 year old with HIV infection is staying with a foster family who is caring for 3 other
foster children in their home. When one of the children acquires pertussis, the foster
mother calls the clinic and asks the nurse what she should do. Which action should the
nurse take first?
A. Remove the child who has HIV from the foster home
B. Report the exposure of the child with HIV to the health department
C. Place the child who has HIV in reverse isolation
D. Review the immunization documentation of the child who has HIV - Answer-d
/.A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the
best way for the nurse to evaluate fluid retention or loss?
a. Measuring the abdominal girth daily
b. Having the child urinate in a bedpan
c. Testing the child's urine for proteinuria
d. Weighing the child at the same time each day - Answer-d
/.A 4 month-old girl is brought to the clinic by her mother because she has had a cold for
2 o 3 days and woke up this morning with a hacking cough and difficulty breathing.
Which additional assessment finding should alert the nurse that the child is in acute
respiratory distress?
a. Bilateral bronchial breath sounds
b. Diaphragmatic respiration
c. A resting respiratory rate of 35 breathe per minute
d. flaring of the nares - Answer-d
/.A 6 year old who has asthma is demonstrating a prolonged expiratory phase and
wheezing and has a35% of personal best peak expiratory flow rate (PEFR) based on
these finding, actions should the nurse take first?
