1. A nurse is teaching a parent of a child with hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? • “I will have my child rest.” • “I will compress the site.” • “I will apply heat.” • “I will elevate the affected part.” 2. A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? • Body weight • Skin integrity • Blood pressure • Respiratory rate 3. Which of the following children should the nurse identify as a potential action of abuse? • A child who has frequent visitors •
A child who uses the call light frequently • A child who has a BMI indicating obesity • A child whose parents answer questions for the child 4. A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? • “My child will take the enzymes to improve her metabolism.” • “My child will take the enzymes 2 hours before meals.” • “My child will take the enzymes following meals.” • “My child will take the enzymes to help digest the fat in foods.” 5. A nurse is assessing a 3 month old. Which of the following findings should he report to the provider? • Unable to pick up an object with his fingers •
Unable to sit without support • Unable to raise head when in prone position • Unable to bring an object to mouth 6. A nurse is admitting a 6 month old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has confirmed the fluid imbalance? • 2 mL/kg/hr. • 0.5 mL/kg/hr. • 7.5 mL/kg/hr. • 15 mL/kg/hr. 7. A nurse is planning care for an infant who has spina bifida and is to undergo surgical ? Which of the following interventions should the nurse include in the plan of care? • Maintain the infant in the supine position • Provide a latex free environment • Limit visitors to immediate family members • Initiate contact precautions 8. A nurse is caring for a child who has just died.
The parents ask to be left alone so that they ? The nurse should: • Discourage this because it will only prolong their grief • Grant their request • Kindly explain that they need to say good bye to their child now and leave • Assess why they feel that this is necessary 9. A nurse is educating new parents on risk factors for sudden infant death syndrome (SIDS). Which of the following statements by a parent would indicate a need for additional teaching? • “I will give my baby a pacifier during naps and at bedtime.” • “Our baby will sleep in my bed because I am breastfeeding.” •
“My baby will be placed on her back when sleeping.” • “We will remove blankets and toys from the crib.” 10. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client would indicate to the nurse a need for further teaching? • “I only need to catheterize myself twice every day.” • “I only use a suppository every night to have a bowel movement.” • “I do wheelchair exercises while watching TV.” • “I carry a water bottle with me because I drink a lot of water.” 11. A parent tells a nurse that her toddler drink a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders? • Rickets • Iron deficiency anemia •
Obesity • Diabetes mellitus 12. A toddler weighs 77 pounds. What is the appropriate maintenance IV fluid rate? • 75 mL/hr. • 45 mL/hr. • 33 mL/hr. • 52 mL/hr. 13. A nurse is caring for a toddler admitted to a pediatric unit. Which of the following statements should the nurse use when preparing to check the child’s vital signs? • “Can you stand still while I feel how warm you are?” • “I am going to take your blood pressure now.” • “I am going to listen to your heart.” •
“Can I listen to your lungs?” 14. A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child? • Rye • Wheat • Barley • Rice 15. A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child’s vital signs? • “I am going to take you blood pressure now.” •
“Can you stand very still while I feel how warm you are?” • “I am going to listen to your heart.” • “Can I listen to your lungs?” 16. A nurse is panning care for a 5 month old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? • Keep the infant NPO for 6 hr. prior the procedure • Place the infant in an infant seat for 2 hr. following the procedure • Hold the infant’s chin to his chest and knees to his abdomen during the procedure • Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min. prior to the procedure 17.
A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider? • Yellow nasal drainage • Poor appetite • Irritability • Facial edema 18. A parent calls a clinic and reports to a nurse that his 2 old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? • “Try switching to a different formula.” • “Bring your baby in to the clinic today.” • “Give your infant an oral rehydration solution.” • “Burp your baby more frequently during feedings.” 19. A nurse is panning home care for a 9 year old child who is discharged following an acute asthma attack. Which of the following growth and developmental stages according to Erikson should the nurse consider in the planning? •
Identity versus role confusion • Initiative versus guilt • Industry versus inferiority • Autonomy versus shame and doubt 20. A nurse is caring for a child who has been physically abused by a family member. Which of the following is an appropriate statement for the nurse to say to the child? • “I promise I won’t tell anyone about this.” • “Your family is bad for doing this to you.” • “Let’s discuss what happened together with your family.” • “It is not your fault that this happened.” 21. A nurse is assessing an infant with Trisomy 21 (Down’s syndrome). Which of the following are common characteristics? (Select all that apply) • Muscular hypertonicity • Large ears • Protruding tongue • Hyperflexibility • Transverse palmar ceases 22. A nurse in an emergency department is assessing a 3 year old child who has a high fever, severe dyspnea, and is drooling. Which of the following interventions is the nurse’s priority?