EXAM QUESTION BANK | NEWEST AC m m m m m
TUAL EXAM COMPREHESIVE QUESTI m m m
ONS AND VERIFIED ANSWERS GRADE
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D A+ | 100% PASS | 2025 UPDATE!
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A nurse is preparing for the admission of an infant with a diagnosis of bro
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nchiolitis caused by the respiratory syncytial virus (RSV). Choose the interv
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entions that would be included in the plan of care. Select all that apply. -
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m✔✔✔ Correct Answer > Place the infant in a private room.
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Place the infant in a room near the nurses' station.
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A nurse is caring for a client who has just been admitted to the nursing
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munit after receiving flame burns to the face and chest. The nurse note
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s a hoarse cough and that the client is expectorating sputum with blac
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k flecks. The client's eyelashes and eyebrows are singed, and the eyeli
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ds are swollen. The client suddenly becomes restless, and his color be
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comes dusky. The nurse interprets this data as indicating which of the
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following? - m
m✔✔✔ Correct Answer > The burn has probably caused laryngeal e
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dema, which has occluded the airway.
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,A nurse reviews the record of a child who was just seen by a health car
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e provider (HCP). The HCP has documented a diagnosis of suspected ao
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rtic stenosis. Which clinical manifestation that is specifically found in c
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hildren with this disorder should the nurse anticipate? -
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m✔✔✔ Correct Answer > Exercise intolerance
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The nurse in the newborn nursery receives a telephone call to prepare
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for the admission of an infant born at 43 weeks' gestation with Apgar
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scores of 1 and 4. When planning for the admission of this infant, the
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nurse's highest priority should be to: -
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m✔✔✔ Correct Answer > Connect the resuscitation bag to the oxyge
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n outlet.
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The child with aortic stenosis shows signs of exercise intolerance, ches
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t pain, and dizziness when standing for long periods. Pallor may be not
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ed, but it is not specific to this type of disorder alone. Options 2 and 4
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are not related to this disorder.
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A nurse is told that a child with rheumatic fever (RF) will be arriving to
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the nursing unit for admission. Which question should the nurse ask th
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e family to elicit information specific to the development of RF? -
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m✔✔✔ Correct Answer > "Did the child have a sore throat or an une
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xplained fever within the past 2 months?"
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Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an
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untreated or partially treated group A β-
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hemolytic streptococcal infection of the upper respiratory tract. Initiall
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y, the nurse determines if
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,the child has had a sore throat or an unexplained fever within the past
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m2 months. Options 1, 2, and 3 are unrelated to RF.
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A nurse assists with admitting a child with a diagnosis of acute-
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stage Kawasaki disease. When obtaining the child's medical history, wh
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ich clinical manifestation is likely to be reported? -
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m✔✔✔ Correct Answer m m
> Conjunctival hyperemia m
During the acute stage of Kawasaki disease, the child presents with fev
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er, conjunctival hyperemia, a red throat, swollen hands, a rash, and enl
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argement of the cervical lymph nodes. During the subacute stage, crac
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king lips and fissures, desquamation of the skin on the tips of the finge
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rs and toes, joint pain, cardiac manifestations, and thrombocytosis occ
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ur. During the convalescent stage, the child appears normal, but signs
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of inflammation may be present.
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A nurse caring for an infant with congenital heart disease is monitoring
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mthe infant closely for signs of congestive heart failure (CHF). The nurs
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e looks for which early sign of CHF? -
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m✔✔✔ Correct Answer > Tachycardia
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The early signs of CHF include tachycardia, tachypnea, profuse scalp s
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weating, fatigue, irritability, sudden weight gain, and respiratory distre
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ss. A cough may occur with CHF as a result of mucosal swelling and irri
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tation, but it is not an early sign. Pallor may be noted in the infant wit
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h CHF, but it is also not an early sign.
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, A nurse is monitoring the daily weight of an infant with congestive he
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art failure (CHF). Which of the following alerts the nurse to suspect flu
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id accumulation and thus to the need to notify the registered nurse?
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- ✔✔✔ Correct Answer > A weight gain of 1 lb in 1 day
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A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of
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mfluid. The nurse should monitor the urine output, monitor for evidenc
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e of facial or peripheral edema, check the lung sounds, and report the
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weight gain. Tachypnea and an increased BP would occur with fluid ac
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cumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid a
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ccumulation, and it usually occurs with exertional activities
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A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. Th
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e infant suddenly becomes cyanotic and the oxygen saturation reading
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drops to 60%. Choose the interventions that the nurse should perform.
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mSelect all that apply. -
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m✔✔✔ Correct Answer > Notify the registered nurse. Prepare to ad
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minister morphine sulfate. Prepare to administer intravenous fluids. Pr
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epare to administer 100% oxygen by face mask.
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The child who is cyanotic with oxygen saturations dropping to 60% is h
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aving a hypercyanotic episode. Hypercyanotic episodes often occur am
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ong infants with tetralogy of Fallot, and they may occur among infants
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whose heart defect includes the obstruction of pulmonary blood flow a
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nd communication between the ventricles. If a hypercyanotic episode
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occurs, the infant is placed in a knee-
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chest position immediately. The registered nurse is notified, who will t
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hen contact the health care provider. The knee-
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chest position improves systemic arterial oxygen saturation by decreas
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ing venous return so that smaller
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