Answers) Detailed Answer Key Questions And Detailed Answers
With Rationale Agrade
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following
actions should the nurse take?
a. Have the toddler wear a disposable gown when in the unit's playroom.
b. Wear sterile gloves when changing the toddler's diapers.
c. Wear a mask when assisting the toddler with meals.
d. Ask visitors to wear an N-95 mask when entering the room. - CORRECT ANSWERS-c. Wear a
mask when assisting the toddler with meals.
Rationale: The nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the
transmission of infections that are spread via large droplet particles expelled in the air.
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the
following findings should the nurse report to the provider?
a. Head lags when pulled from a lying to a sitting position
b. Absence of startle and crawl reflexes
c. Inability to pick up a rattle after dropping it
d. Rolls from back to side - CORRECT ANSWERS-a. Head lags when pulled from a lying to a
sitting position
Rationale: At the age of 5 months, the infant should have no head lag when pulled to a sitting
position; therefore, the nurse should report this finding to the provider.
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of
the following statements by the nurse indicated an understanding of this ingestion?
a. The absence of oral burns excludes the possibility of esophageal burns.
b. Treatment focuses on neutralization of the chemical.
c. Injury by a corrosive liquid is more extensive than by a corrosive solid.
,d. Immediate administration of activated charcoal is warranted. - CORRECT ANSWERS-c.
Injury by a corrosive liquid is more extensive than by a corrosive solid.
Rationale: The coating action of liquids permits larger areas of contact with tissues and results in more
extensive injury.
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate
term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the
following statements should the nurse include when teaching the child's parent?
a. The PICC line will last several weeks with proper care.
b. The The public health nurse will rotate the insertion site every 3 days.
c. You will need to make certain the arm board is in place at all times.
d. Your child will go to the operating room to have the line placed. - CORRECT ANSWERS-a.
The PICC line will last several weeks with proper care.
Rationale: PICC lines are the preferred venous access device for short to moderate term IV therapy. They
can remain in place for long periods with proper care.
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100ml IV to infuse
over 4 hr. The drop factor of the manual IV tubing is 60 gtt/ml. The nurse should set the manual IV
infusion to deliver how many gtt/min? (Round the answer to the nearest whole number) -
CORRECT ANSWERS-25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions
should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
c. Explain procedures using medical terminology
d. Stop the assessment if the child becomes uncooperative. - CORRECT ANSWERS-b. Minimize
physical contact with the child initially.
Rationale: The nurse should initially minimize physical contact with the toddler, and then
progress from the least traumatic to the most traumatic procedures.
, A nurse is caring for an 18-yr old adolescent who is up to date on immunizations and is planning to
attend college. The nurse should inform the client that he should receive which of the following
immunizations prior to moving into a campus dormitory.
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. rotavirus
d. Herpes zoster - CORRECT ANSWERS-b. Meningococcal polysaccharide
Rationale: The meningococcal polysaccharide immunization is used to prevent infection by
certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening
illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia,
which affects the blood. Both of these conditions can be fatal. College freshmen, particularly
those who live in dormitories, are at an increased risk for meningococcal disease relative to other
persons their age. Therefore, the Centers for Disease Control and Prevention has issued a
recommendation that all incoming college students receive the meningococcal immunization.
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the
nurse include as being the most common food allergy in children.
a. Cow's milk
b. Wheat bread
c. Corn syrup
d. Eggs - CORRECT ANSWERS-a. Cow's milk
Rationale: According to evidence-based practice, the nurse should instruct the parent that cow's
milk is the most common food allergy in children. Some children are sensitive to the protein,
called casein, found in cow's milk. They have difficulty metabolizing the casein and are,
therefore, allergic to cow's milk.
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the
parent indicates an understanding of the teaching?
a. I lock my medications in the medicine cabinet