Practice 2023 A all correct
answers with rationale
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?
"Shake the medication prior to administration."
Rationale: The nurse should instruct the parent to shake the
medication prior to administration to disperse the medication
evenly within the suspension.
A nurse is teaching a group of parents about infectious mononucleosis.
Which of the following statements by a parent indicates an understanding
the teaching?
"Mononucleosis is caused by an infection with the Epstein-Barr virus."
Rationale: The nurse should identify that mononucleosis is a mildly
contagious illness that occurs sporadically or in groups, and is
primarily caused by the Epstein-Barr virus.
A nurse is creating a plan of care for a school-age child who has heart
disease and has developed heart failure. Which of the following interventions
should the nurse include in the plan?
Provide small, frequent meals for the child.
,Rationale: The metabolic rate of a child who has heart failure is high
because of poor cardiac function. Therefore, the nurse should
provide small, frequent meals for the child because it helps to
conserve energy.
A nurse is providing anticipatory guidance to the guardian of a toddler. Which
of the following expected behavior characteristics of toddlers should the
nurse include?
Expresses likes and dislikes
Rationale: The nurse should include that expressing likes and
dislikes is an expected behavior of toddlers. This is the time in life
when a toddler is developing autonomy and self-concept. They will
try to assert themselves and frequently refuse to comply. The
guardian should allow the child to have some control, but also set
limits for them so they learn from their behavior and learn to
control their actions.
A nurse in an emergency department is caring for a school-age child who is
experiencing an anaphylactic reaction. Which of the following is the priority
action by the nurse?
Administer epinephrine IM
Rationale: When using the urgent vs. non-urgent approach to client
care, the nurse should determine that the priority action is
administering epinephrine IM to the child. During an anaphylactic
reaction, histamine release causes bronchoconstriction and
vasodilation. This is an emergency because ultimately it causes
decreased blood return to the heart.
, A nurse in a pediatric emergency department is planning care for an
adolescent. Based on the information in the adolescent's medical record,
which of the following actions should the nurse plan to take?
Select all that apply.
Apply supplemental oxygen
Rationale: According to the medical record and chest x-ray report, the
adolescent could potentially have a pneumothorax. Also according to the
medical record and chest x-ray report, the adolescent's oxygen saturation
level is decreasing, which indicates hypoxia. Therefore, the nurse should plan
to administer supplemental oxygen.
Prepare for chest tube insertion
Rationale: According to the medical record and chest x-ray report, the
adolescent could potentially have a pneumothorax. A pneumothorax is the
presence of air in the pleural cavity, which results in decreased lung
expansion. The adolescent could experience dyspnea, tachypnea,
tachycardia, hypoxia, and pain. This requires prompt intervention by the
provider, such as the placement of a chest tube into the thoracic cavity to
remove air and fluid from the pleural space, if present, allowing the lung to
re-expand.
A nurse in an emergency department is caring for a school-age child who has
epiglottitis. Which of the following actions should the nurse take?
Monitor the child's oxygen saturation