Question: An adolescent with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides to the pediatric nurse about their HIV status and asks the nurse not to reveal their HIV status to their parents. Which response by the nurse is best?

Answer Options: “I must share this information with your family.” “I must share this information with your partner.” “Would you like me to help you tell your parents?” “The information you confide in me is confidential.”

Answer: “The information you confide in me is confidential.”

Question: The nurse is evaluating the effectiveness of fluid resuscitation in a school age child during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

Answer Options: The body weight has increased. The blood pressure is 90/60 mm Hg. The fluid intake is less than urinary output. The urine output is more than 35 mL per hour.

Answer: The urine output is more than 35 mL per hour.

Question: When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate which type of feeding?

Answer Options: Full-strength formula Half-strength formula Oral electrolyte solution Cereal-thickened formula

Answer: Oral electrolyte solution

Question: The nurse teaches a client taking desmopressin nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when the client makes which comment?

Answer Options: “I should report nasal congestion.” “I should report any signs of respiratory infection.” “I should use the same nostril each time I take the medicine.” “I should check for sores in my nose while taking this medication.”

Answer: “I should use the same nostril each time I take the medicine.”

Question: A parent calls the nurse to report that their toddler has just been burned on the arm. What should the nurse advise the parent to do first?

Answer Options: Call the child’s HCP immediately, and then wrap the arm in a clean cloth Run cool water over the burned area, and then wrap it in a clean cloth. Pack the arm in ice, and then take the child to the closest emergency department. Rub the burned area with an antibacterial ointment, and then call the child’s health care provider (HCP).

Answer: Run cool water over the burned area, and then wrap it in a clean cloth.

Question: A nurse is assessing a 12-year-old child diagnosed with a fractured wrist. The wrist has been in a cast for 3 weeks. Which statement made by the client requires intervention by the nurse?

Answer Options: “My fingers are warm, and I can wiggle them easily.” “My parent makes me wrap my arm in a plastic bag when I shower.” “I use a hair dryer to blow cool air into the cast when my arm itches.” “Whenever I have pain I take the acetaminophen/oxycodone we have at home.”

Answer: “I use a hair dryer to blow cool air into the cast when my arm itches.”

Question: An adolescent girl who comes to the emergency department with multiple bruises on the face and arms, a black eye, and a broken nose states that these injuries occurred when she fell down the stairs. The nurse suspects that the adolescent may have been physically assaulted. What should the nurse do next?

Answer Options: Ask the client directly about the possibility of physical abuse. Ask the client what they did to make someone beat them so badly. Discuss with the client what they can do to deescalate the situation next time. Tell the client that it is difficult to believe that such injuries resulted from a fall.

Answer: Ask the client directly about the possibility of physical abuse.

Question: The nurse is planning care for a toddler 1 day after having surgery to create a tracheostomy. Which nursing action is the priority goal for the toddler at this time?

Answer Options: Maintain a patent airway. Relieve anxiety about breathing. Keep the secretions moist with saline. Teach the client about tracheostomy care.

Answer: Maintain a patent airway.

Question: The parent of a toddler tells the nurse their child is “fussy” and not as “easygoing” as their other children. The parent is having difficulty feeding the child because the child fusses and cries when served a meal. What instructions should the nurse give the parent?

Answer Options: Do not feed the child if they cry. Provide structured feeding times and routines. Allow the child to determine when feeding should occur. Give the child finger foods and let them eat when they want.

Answer: Provide structured feeding times and routines.

Question: The nurse is caring for a child with Tetralogy of Fallot experiencing a hypercyanotic spell. Which of the following actions should the nurse implement first?

Answer Options: Start IV fluids Give morphine Administer oxygen Place child in knee-chest position

Answer: Place child in knee-chest position.

Question: A nurse is teaching a new parent how to prevent burns in the home. Which statement by the parent indicates more teaching is required?

Answer Options: “I will set my hot water heater to 120°F (49°C).” “I will not hold my infant while drinking coffee.” “I will heat my infant’s formula in the microwave.” “I will keep loose appliance cords tied up on the counter.”

Answer: “I will heat my infant’s formula in the microwave.”