Question: A nurse is caring for a group of clients.
Answer Options: A school-age child who has a rectal body temperature of 37.3°C (99.1°F), A 3-month-old infant who has a respiratory rate of 30/min, An 18-month-old toddler who has a heart rate of 68/min, An adolescent who has a BP of 132/82 mm Hg.
Answer: A 3-month-old infant who has a respiratory rate of 30/min
Question: A nurse is caring for a 1-month-old infant.
Answer Options: Why do you feel like your baby cries a lot?, Your baby’s crying is a way to communicate with you., Is it possible that you have spoiled your baby?, Letting your baby cry will teach them how to self-soothe.
Answer: Your baby’s crying is a way to communicate with you.
Question: A nurse is planning to administer diphenhydramine 1.25 mg/kg IV to a school-age child who weighs 55 lb.
Answer Options: Calculation for administration
Answer: 1.25 mL
Question: A nurse is teaching a newly licensed nurse about infant safety.
Answer Options: Secure the infant’s car seat behind an airbag, Provide an infant with a one-piece pacifier for non-nutritive sucking, Position a 1-month-old infant supine on a soft mattress, Place an infant who is 5 months old in a high chair to feed.
Answer: Provide an infant with a one-piece pacifier for non-nutritive sucking
Question: A nurse is preparing to administer an enteral feeding to an adolescent who has an NG tube.
Answer Options: Flush the tube with water, Set the administration rate on the feeding pump, Attach the feeding bag tubing to the end of the NG tube, Check the pH of the gastric secretions.
Answer: Check the pH of the gastric secretions
Question: A nurse in an emergency department is caring for a toddler who has manifestations of epiglottitis.
Answer Options: Obtain an x-ray of the child’s neck, Administer intravenous antibiotics, Initiate droplet precautions, Place intubation equipment at the bedside.
Answer: Place intubation equipment at the bedside
Question: A nurse is providing teaching about home care to the parent of a child who has scabies.
Answer Options: Wash the child’s hair with shampoo containing ketoconazole, Soak combs and brushes in boiling water for 10 min, Apply petroleum jelly to the affected areas, Treat everyone who came into close contact with the child.
Answer: Treat everyone who came into close contact with the child
Question: A nurse is preparing to administer an oral medication to a preschooler.
Answer Options: Dilute the medication with 8 oz of water, Mix the medication with the child’s favorite food, Give 4 oz of milk with the medication, Provide an ice pop after administering the medication.
Answer: Mix the medication with the child’s favorite food
Question: A nurse in an emergency department is caring for a 3-month-old infant.
Answer Options: Administer ceftriaxone, Initiate neutropenic precautions, Administer pneumococcal conjugate vaccine, Initiate serum glucose testing every 1 hr.
Answer: Administer ceftriaxone
Question: A nurse is providing teaching for a 20-year-old adolescent who has syphilis.
Answer Options: “I have to notify the public health department.”, “You need to come back in a week for retesting.”, “I have to contact your parents.”, “Let’s review the side effects of metronidazole.”
Answer: “I have to notify the public health department.”
Question: A nurse in the emergency department is preparing to discharge a 3-year-old child.
Answer Options: You should cut and file your child’s fingernails frequently, You should use a mild detergent for your child’s laundry, Your child’s condition is contagious when lesions are present, Your child will experience occasional flare-ups of this condition, You should apply emollients to your child’s skin after bathing, You should apply a thick layer of pimecrolimus cream to your child’s lesions, You can apply gloves to your child’s hands.
Answer: You should cut and file your child’s fingernails frequently, You should use a mild detergent for your child’s laundry, Your child will experience occasional flare-ups of this condition, You should apply emollients to your child’s skin after bathing
Question: A nurse is developing a plan of care for an adolescent who is experiencing a vaso-occlusive crisis.
Answer Options: Initiate IV fluids, Apply ice to joints, Assess for hyperkalemia, Administer antispasmodics.
Answer: Initiate IV fluids
Question: A nurse in the emergency department is caring for a toddler.
Answer Options: Keep the child NPO, Prepare the child for flexible endoscopy.
Answer: Keep the child NPO followed by prepare the child for flexible endoscopy.
Question: A nurse is caring for a school-age child who has pertussis.
Answer Options: Restrict oral fluids to 500 mL per day, Report the diagnosis to the public health department, Place the child in a protected environment for 48 hr, Administer the pertussis vaccine.
Answer: Report the diagnosis to the public health department
Question: A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
Answer Options: Hypervolemia, Low hemoglobin, Hyperkalemia, Metabolic alkalosis
Answer: Low hemoglobin
Question: A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse’s priority?
Answer Options: Temperature, Serum electrolytes, Respiratory status, Intracranial pressure
Answer: Intracranial pressure
Question: A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Answer Options: Vomiting, Urticaria, Hypotension, Stridor
Answer: Hypotension
Question: A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
Answer Options: The purpose of this device is to allow for neck movement during the healing process; The purpose of this device is to immobilize the cervical spine; Apply talcum powder under the vest to limit friction; Turn the screws on the device once each day.
Answer: The purpose of this device is to immobilize the cervical spine
Question: A nurse is caring for several clients who were admitted to the emergency department. Which of the following client scenarios represents the Secondary Survey process?
Answer Options: A client admitted with a foreign body obstruction; A client admitted after a fall from a roof; A client admitted after a motor vehicle accident; A client admitted for appendicitis.
Answer: A client was admitted to the emergency department following a motor vehicle accident resulting in a liver laceration. The stabilized client was transferred to the intensive care unit and a follow-up x-ray notes a broken clavicle.
Question: A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)
Answer Options: Increase hematocrit, Increased heart rate, Increased temperature, Increased respiratory rate, Increased blood pressure
Answer: Increased heart rate, Increased respiratory rate, Increased blood pressure