CMS Practice Questions
A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular Septal Defect C. Coarctation of the Aorta D. Patent Ductus Ateriosus
A. Transposition of the great arteries An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.
A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. Children commonly begin having imaginary friends when they reach school age. B. Notify your provider if the imaginary friend persists longer than 6 months. C. Have your child take responsibility for actions I the tries to blame the imaginary friend. D. Set limits by not allowing your child to have the imaginary friend present during family meals.
Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions. Incorrect Answers:A. Imaginary playmates are common during the preschool years due to the high level of imagination among this age group.B. Imaginary playmates are common during the preschool years and are not a cause for concern as long as the preschooler also socialized with other children.DO. The nurse should instruct the guardian that this behavior is expected and that pretending with the preschooler is okay.
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hours. Incorrect Answers: A. 1.010 is within the expected reference range for urine specific gravity. C. 1.020 is within the expected reference range for urine specific gravity. D. 1.005 is decreased urine specific gravity, which could indicate excessive fluid intake rather than dehydration.
A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure
A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers: B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra-abdominal pressure.
A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? A. Corn tortilla with black beans B. Pizza C. Canned soup D. Hot dogs
A. Corn tortilla with black beans Children who have celiac disease are placed on a gluten-free diet. Gluten is found in wheat, rye, and barley. Selecting products made from corn indicates an understanding of the teaching, as corn and beans are gluten-free foods. Incorrect Answers: B. Pizza often contains gluten. Gluten is found in wheat, rye, and barley and should be avoided by a child who has celiac disease. C. Prepared soups often contain gluten. D. Hot dogs and hot dog buns often contain gluten.
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 lagging when the infant is 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. Rolling from back to side
A. Head lagging when the infant is pulled from a lying to a sitting position 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. Incorrect Answers: B. The startle reflex disappears by the age of 4 months, and the crawl reflex disappears around the age of 6 weeks. C. At the age of 5 months, the infant can visually follow a dropped object but is unable to pick up the object until around the age of 6 months. D. The infant should be able to roll from back to side at the age of 4 months.
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? A. 6 months old B. 12 months old C. 18 months old D. 24 months old
B. 12 months old The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills—sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)—should also help the nurse estimate the infant's age as 12 months. Incorrect Answers: A. At 6 months, an infant would not have 6 teeth or demonstrate these skills. C. The infant must be younger than 18 months old since her anterior fontanel is still open. In addition, an infant of this age should have 12 teeth. D. At 24 months, an infant should have all of her primary teeth and be able to speak in 2-word phrases.
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
B. Rigid abdomen Incorrect Answers: A. Right lower quadrant abdominal pain is an expected manifestation of appendicitis. C. Decreased or absent bowel sounds are an expected manifestation of appendicitis. D. Tachycardia and rapid, shallow breathing are expected manifestations of appendicitis.
A nurse is taking the history of and performing a physical on a school-age child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD? A. The child's family has a middle-class socioeconomic background. B. The child had prenatal exposure to alcohol on a regular basis. C. Both siblings of the child show moderate activity levels in school and play activities. D. The child's mother currently has diabetes mellitus.
B. The child had prenatal exposure to alcohol on a regular basis. Prenatal exposure to alcohol on a regular basis is a contributing factor to ADHD, along with prenatal nicotine exposure and exposure to lead or mercury. Incorrect Answers:A. The child's socioeconomic background is not likely to cause ADHD. Risk factors include prenatal alcohol exposure, lead exposure, genetic factors, and traumatic brain injury.C. Sibling activity level is not likely to cause ADHD.D. There is no indication that a current illness of the child's mother is a risk factor for ADHD.
A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? A. Initiate contact precautions for the child. B. Explain to the child's parents that chemotherapy will start 3 months after surgery. C. Put a "no abdominal palpation" sign over the child's bed. D. Prepare the child for a spinal tap.
C. Put a "no abdominal palpation" sign over the child's bed. The nurse should place a sign over the child's bed stating "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could prompt metastasis. Incorrect Answers: A. Contact precautions are indicated for children who are suspected to have illnesses transmitted by client contact or contact with items in the client's environment. B. Radiology and chemotherapy are begun immediately following surgery. D. A spinal tap is a diagnostic test that provides samples of spinal fluid to confirm infection or abnormal cells.
A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint
D. Apply an ice pack to the joint Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint. Incorrect Answers: A. The nurse should avoid giving clients with hemophilia aspirin or NSAIDs because these medications can interfere with the action of platelets. B. Passive range-of-motion exercises should never be performed on a client with hemophilia. Over-stretching and tearing could inadvertently occur, resulting in further joint bleeding. C. Cryoprecipitate is no longer used to treat clients with hemophilia due to the inability to remove hepatitis and HIV completely from the product. Hemophilia is currently treated with factor VIII replacement products or a synthetic form of vasopressin.
A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure
A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers: B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra-abdominal pressure.
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production
C. Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia. Incorrect Answers: A. This finding indicates mild dehydration. A toddler experiencing severe dehydration would exhibit intense thirst. B. This finding indicates mild to moderate dehydration. A toddler experiencing severe dehydration would exhibit a capillary refill of 4 seconds or greater and skin tenting. D. This finding indicates moderate dehydration. A toddler experiencing severe dehydration would exhibit an absence of tears and sunken eyeballs.
A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."
B. Keep hair off your forehead." Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. Incorrect Answers: A. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. C. Tetracycline should be taken on an empty stomach to improve the absorption of the medication. D. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation.
A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed
B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture. Incorrect Answers: A. The nurse should avoid performing nasotracheal suctioning. This procedure is contraindicated due to the risk of injury to the child's brain if a skull fracture is present. C. The nurse should avoid bright lights due to the child's risk of increased intracranial pressure. The nurse should provide an environment with decreased stimulation. D. The nurse should position the child with the head of the bed elevated and the child's head in a midline position to assist with preventing increased intracranial pressure.
A nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."
C. "Keep the cast above the level of your heart." Immediately following the injury (and for at least the first 48 hours), the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return. Incorrect Answers: A. The child should not insert any objects between the cast and the skin, as scratches or abrasions could lead to infection. B. The child should rest and avoid strenuous activities but should use the muscles of the leg and the joints above and below the cast. D. Fiberglass casts do not deteriorate as much as plaster casts do when wet, but the child should keep the cast dry. Wet cotton batting and stocking net inside the cast will absorb water and could lead to skin breakdown.
A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough
C. Nasal flaring Acute laryngotracheobronchitis (croup) causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions. Incorrect Answers: A. Tachycardia, not bradycardia, is an indication of impending airway obstruction. B. Tachypnea, not bradypnea, is an indication of impending airway obstruction. D. A barking cough is a classic manifestation of acute laryngotracheobronchitis; however, it is not an indication of impending airway obstruction.
A nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve your joint pain." B. "Take opioids routinely." C. "Attend school regularly." D. "Adhere to an arthritis diet."
C. "Attend school regularly." The nurse should encourage this adolescent with idiopathic arthritis to attend school. The adolescent should attend school even on days when joint pain or stiffness occurs. Incorrect Answers: A. The client should apply moist heat to relieve joint pain and stiffness. B. Opioid pain medications are not routinely prescribed for pain associated with juvenile idiopathic arthritis. The nurse should instruct the client to take NSAIDs on a routine schedule to maintain adequate therapeutic levels. D. There is no "arthritis diet" or certain foods for the adolescent to avoid to decrease symptoms of arthritis. However, to avoid excessive weight gain, the client should monitor and match the caloric intake to individual energy needs.
A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure
C. Obtain the adolescent's weight prior to the procedure. The nurse should obtain a baseline weight prior to the initiation of the procedure and again following the procedure. Incorrect Answers: A. The nurse should elevate the head of the adolescent's bed to minimize upward pressure on the diaphragm from the dialysate. B. The nurse should have the adolescent empty his bladder prior to the procedure to allow maximum space in the anterior peritoneal cavity. The adolescent does not need to drink fluids prior to the procedure. D. The nurse should monitor the adolescent's vital signs at least every hour during the procedure.
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot
D. Standing on 1 foot The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds. Incorrect Answers: A. Skipping is a developmental task expected of a 4-year-old child. B. Hopping on 1 foot is a developmental task expected of a 4-year-old child. C. Throwing a ball overhead is a developmental task expected of a 4-year-old child.
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent
B. Inactivity and thumb sucking A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair. Incorrect Answers: A. Protest is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Protest is the first stage of separation anxiety, which includes attempting to escape the area to find a parent.
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."
C. "I should make sure my baby's clothing does not have buttons." The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration. Incorrect Answers: A. The nurse should instruct the parent to avoid the use of talcum powder to reduce the risk of aspiration pneumonia if inhaled. B. The nurse should instruct the parent to avoid using a drop-side crib to reduce the risk of suffocation and falls. D. The nurse should instruct the parent to use a crib that has slats that are <6 cm (2.36 in) apart to reduce the risk of suffocation.
A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers
C. A blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. Incorrect Answers: A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.
A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. C. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.
C. Children who were born prematurely are more likely to be maltreated. Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have a greater number of additional stressors and restricted access to available support systems.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale
C. FACES pain rating scale The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. Incorrect Answers: A. A word graphic rating scale uses a line with words identifying a scale of no pain to the worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. Children who are 3 years old will have difficulty understanding this scale. B. The color tool uses 4 markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. D. Using a numeric scale from 0 to 10 to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.
A nurse is providing teaching to the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods in the infant's diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infant's first tooth erupts D. At 4 to 6 months of age
D. At 4 to 6 months of age The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age. Incorrect Answers: A. The disappearance of the extrusion reflex, rather than the rooting reflex, is an indicator of the infant's developmental readiness for solid foods. B. Infants between 2 and 3 months of age still have the extrusion reflex and are not developmentally ready for solid foods. C. The timing of the eruption of the infant's first tooth varies greatly and t is not an appropriate indicator for introducing solid foods.
A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea
D. Chronic diarrhea Chronic diarrhea is an expected finding for a preschooler who has HIV. Incorrect Answers: A. Generalized petechiae are not a manifestation of HIV in a preschooler. B. Jaundice is not a manifestation of HIV in a preschooler. C. Failure to thrive and weight loss are expected findings for a preschooler who has HIV.
A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardiorespiratory monitor
D. Maintain a cardiorespiratory monitor Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed. Incorrect Answers: A. Pertussis causes paroxysms of coughing with frequent vomiting. Therefore, infants who have pertussis are at risk of fluid volume deficit. B. The nurse should take this action when caring for a child who has a mumps infection, which causes enlarged, painful parotid glands. C. The nurse should initiate standard and droplet precautions when providing care for a client who has pertussis.
A nurse is caring for a 16-year-old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? A. "Herbal medication can be effective but should be monitored by your provider." B. "You should place a cold compress on your lower abdomen to decrease inflammation." C. "You should limit exercise, which can increase the pain." D. "Avoid touching the painful areas because this can increase your discomfort."
A. "Herbal medication can be effective but should be monitored by your provider." Herbal medicine may be helpful in relieving menstrual pain. However, there is a risk of toxicity and drug interactions if herbal medicine is taken in the wrong doses or with other medications. The nurse should ask the client if she is using herbal medication and document the dose and effects. Incorrect Answers: B. Dysmenorrhea can result from uterine ischemia and lower abdominal cramping. A cold compress causes vasoconstriction and can increase uterine ischemia. A heating pad or hot bath might provide relief of cramping through muscle relaxation and vasodilation, which can help minimize uterine cramping. C. Exercise helps relieve pain by increasing vasodilation, thereby reducing uterine ischemia, which is a cause of dysmenorrhea. Pelvic rocking is a helpful exercise that the nurse can recommend. D. Therapeutic touch can provide pain relief. Massaging the lower back can help relax the muscles and increase pelvic blood flow. Also, effleurage (gentle and rhythmic touching) can help distract the client from the pain and provide an alternative focal point.
A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic cholestasis E. Retinal detachment
A. Enlarged heart B. Enuresis C. Leg ulcers E. Retinal detachment Chronic vaso-occlusive phenomena result from the obstruction of organs by red blood cells, leading to stasis and enlargement of the organs, infarction due to ischemia, and scarring. An enlarged heart, enuresis, leg ulcers, and retinal detachment are manifestations of chronic vaso-occlusive phenomena. Incorrect Answer: D. Intrahepatic cholestasis is a manifestation of chronic vaso-occlusive phenomena. Extrahepatic cholestasis is caused by the blockage of bile flow from the liver due to a source outside of the liver, usually stones in the common bile duct. Intrahepatic cholestasis is caused by the blockage of bile flow from the liver due to a source outside of the liver such as scarring.
A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals
A. Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client. Incorrect Answers: B. UTI is a common complication of myelomeningocele. However, neither myelomeningocele nor UTI requires contact precautions. C. UTI is a common complication of myelomeningocele. Straining urine is essential for urolithiasis (urinary calculi) or stones in the urinary system, not for myelomeningocele or UTI. D. Women should take folic acid during pregnancy to reduce the risk of neural tube defects such as myelomeningocele.
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering B. Insert a dull knitting needle into the cast to rub itchy skin C. Exercise fingers every 8 hr for the first 24 hr D. Draw on the cast using magic markers
A. Place a plastic bag over the cast when showering The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Incorrect Answers: B. Placing any instruments inside the cast can injure the skin and cause an infection. C. The fingers should be moved and exercised every 4 hours for the first 24 hours. D. Fiberglass cast material is porous; therefore, magic markers should not be used to draw on or autograph the cast.
A nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. Clamp the infant's catheter for 30 minutes each day B. Give the infant a tub bath once per day C. Apply antibacterial ointment to the infant's penis once per day D. Decrease the infant's fluid intake for 3 days
C. Apply antibacterial ointment to the infant's penis once per day The nurse should instruct the guardian to apply an antibacterial ointment to the infant's penis once daily to decrease the risk of infection. Incorrect Answers: A. The nurse should instruct the guardian to avoid clamping the catheter at any time. B. The nurse should instruct the guardian to avoid giving the infant tub baths until the catheter and stent are removed and bathing is approved by the provider. D. The nurse should instruct the guardian to increase the infant's fluid intake.
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day C. Give pancreatic enzymes to the child with meals and snacks D. Ensure the child's dietary intake of calcium and iron is adequate Check Answer
D. Ensure the child's dietary intake of calcium and iron is adequate A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption of and effects from the lead. Dietary recommendations should include milk as a good source of calcium. Incorrect Answers: A. Vitamin C does not influence absorption or excretion of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, a reduced intake can result in a vitamin C deficiency. B. A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of lead. C. Pancreatic enzymes are administered to children who have cystic fibrosis, not an elevated blood lead level.
A nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? A. 2 months B. 4 months C. 6 months D. 8 months
6 months Because the infant was born 8 weeks prematurely, the nurse should use this data to determine that the infant's setback age is 6 months. Therefore, the nurse should expect the infant to have achieved the developmental milestones of a 6-month-old infant. Incorrect Answers: A. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 2 months. B. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 4 months. D. The nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old.
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair
A. Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed. Incorrect Answers: B. Infants who have a cleft lip and palate are typically "noisy" feeders due to the increased amount of air that is swallowed during a feeding. The nurse should watch the infant carefully for signs of distress during a feeding such as a wrinkled brow, elevated eyebrows, or watering eyes. If these distress signs are noted, the nurse should remove the nipple and allow time for the infant to swallow the formula. C. Formula is expected to appear in the nose of an infant who has a cleft lip and palate due to a lack of separation between the oral and nasal cavities. D. Parents and caregivers should be encouraged to begin feeding the infant as soon as possible. This opportunity enables the caregivers to gain experience and confidence in their ability to feed the infant prior to discharge, which typically occurs before the surgical repair.
A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis
A. Hydrocephalus In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the infant for this condition. Incorrect Answers: B. Congenital hypotonia is a paralytic form of spinal muscular atrophy that is characterized by progressive weakness and wasting of skeletal muscles; therefore, the infant should not be monitored for this complication. C. Otitis media results from blocked eustachian tubes and is not related to neural tube defects; therefore, the infant should not be monitored for this condition. D. Osteomyelitis results from an organism gaining access to the bone; therefore, the infant should not be monitored for this condition.
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenzae type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)
A. Inactivated poliovirus vaccine (IPV) The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age. Incorrect Answers: B. The nurse should verify that the child received the Hib vaccine at age 2, 4, and 6 months as well as at age 12 to 15 months. This immunization is not routinely administered at 6 years of age. C. The nurse should verify that the child received the pneumococcal conjugate vaccine at 2, 4, 6, and 12 to 15 months of age. This immunization is not routinely administered at 6 years of age. D. The nurse should verify that the child received the HBV vaccine within 12 hours after birth and received additional doses at 1 to 2 months and 6 to 18 months of age. This immunization is not routinely administered at 6 years of age.
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A. Measure the client's weight daily B. Check for tears C. Palpate the fontanel D. Assess skin turgor
A. Measure the client's weight daily When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight. Incorrect Answers: B. Checking for the absence of tears is part of a hydration assessment. However, the lack of tears does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority. C. Palpating the fontanel is part of a hydration assessment. However, unless the fontanel is extremely sunken, this assessment does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority. D. Assessing skin turgor is part of a hydration assessment. However, unless the skin is extremely slow to respond, this assessment does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another assessment that is the priority.
A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease THE RISK of a vast-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain
A. Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy to help prevent sickle cell crisis. Maintaining adequate hydration can reduce the risk of sickle cell formation. Incorrect Answers:B. Oxygen might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis.C. A blood transfusion might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis.D. The nurse can administer ibuprofen to manage the pain of a sickle cell crisis, but this measure will not prevent a crisis from occurring.
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)
A. Remove bibs before the infant goes to sleep The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. Incorrect Answers: B. The nurse should instruct the parent to dress the infant in a 1-piece sleep sack and avoid using blankets to decrease the risk of suffocation. C. The nurse should instruct the parent to avoid placing the infant in direct sunlight for more than 2 to 3 minutes at a time. If the infant will be exposed to sunlight for a longer period, the parent should cover any exposed areas of skin. D. The nurse should instruct the parent to set the hot water heater to no more than 49°C (120°F) to prevent burn injuries.
A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions
B. Administer oral analgesics prior to exercises Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort. Incorrect Answers: A. The nurse should implement contact precautions for a client with poliomyelitis. This virus is spread by direct contact with feces and oropharyngeal secretions. C. Respiratory complications from poliomyelitis are due to paralysis of the respiratory muscles. The nurse should assess the child for signs of weak respiratory effort such as difficulty talking, ineffective coughing, and shallow and rapid respirations. D. Seizures are not an expected complication of a poliomyelitis infection.
A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A. Dullness with chest percussion B. Heart rate 118/min C. Conjunctival discharge D. Respiratory rate 28/min
B. Heart rate 118/min The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia. Incorrect Answers: A. The nurse should identify that dullness with chest percussion is an indication of consolidation of infection. Therefore, this finding does not indicate that treatment has been effective. C. The nurse should identify that conjunctival discharge is a manifestation of allergic rhinitis or conjunctivitis. This finding does not indicate effective treatment of pneumococcal pneumonia. D. The nurse should identify that a respiratory rate of 28/min is above the expected reference range for a 6-year-old child. A child who has pneumococcal pneumonia will exhibit tachypnea and shallow respirations.
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
B. Minimize physical contact with the child initially The nurse should initially minimize physical contact with the toddler and progress from the least traumatic to the most traumatic procedures. Incorrect Answers: A. The nurse should start with the least invasive interventions and proceed to the more invasive. The head-to-toe approach is recommended for preschool-age and older children. C. The nurse should describe procedures using age-appropriate language the child can understand. D. If the child becomes uncooperative, the nurse should perform the procedures more quickly.
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L
B. Oxygen saturation 85% The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately. Incorrect Answers: A. A blood glucose level of 140 mg/dL is above the expected reference range and might require intervention; however, this finding does not need to be reported to the provider immediately. C. An RBC of 3.2 million/uL is below the expected reference range and might require intervention; however, this finding does not need to be reported to the provider immediately. D. A serum sodium level of 156 mEq/L is above the expected reference range and might require intervention; however, this finding does not need to be reported to the provider immediately.
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCs 2.5 million/uL C. WBCs 4,000/mm^3 D. Hct 60%
B. RBCs 2.5 million/uL An RBC count of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count. Incorrect Answers: A. A platelet count of 500,000 mm^3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. C. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC count. D. An Hct level of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.
A nurse is assessing a 6-year-old child who is immediately postoperative following a tonsillectomy. Which of the following findings should the nurse report to the provider? A. The child has a small amount of dark brown blood between the teeth B. The child is swallowing frequently C. The child has a heart rate of 118/min D. The child refuses the application of an ice collar
B. The child is swallowing frequently The nurse should identify that frequent swallowing is a manifestation of hemorrhage. Therefore, the nurse should immediately notify the provider of this finding. Incorrect Answers: A. The nurse should identify that a small amount of dark brown blood between the teeth is an expected finding following a tonsillectomy. The child might also have dark brown blood in the nares. C. The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. D. The nurse should identify that refusing an ice collar is an expected response from a child who is postoperative following a tonsillectomy.
A nurse is caring for an infant who is breastfed and is receiving amoxicillin for an upper respiratory infection. An assessment of the mouth reveals whitish patches on the tongue that will not scrape off. Which of the following actions should the nurse take? A. Offer the infant water before feedings B. Discontinue amoxicillin C. Administer an antifungal medication after feedings D. Give the infant formula instead of breast milk
C. Administer an antifungal medication after feedings The nurse should administer an antifungal medication to the infant after feedings to ensure adequate contact time with the oral mucosa and tongue to enhance treatment of the oral candidiasis. Incorrect Answers: A. The nurse should rinse the infant's mouth with water after feedings and prior to the application of antifungal medication. B. The nurse should identify that oral candidiasis is an adverse effect of antibiotic therapy. The nurse should implement measures to treat the candidiasis rather than discontinue treatment for the respiratory infection. D. The nurse should identify the need to treat both the infant and the mother for candidiasis simultaneously rather than discontinuing breastfeeding`.
A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids B. Give the child magnesium hydroxide PO C. Prepare the child for a barium enema D. Inform the parents that the child will need a colostomy
C. Prepare the child for a barium enema The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children with intussusception are treated with the barium enema and do not require surgical intervention. Incorrect Answers: A. Intussusception is not an inflammatory process but a mechanical obstruction. B. Abdominal pain observed with intussusception is a contraindication for receiving magnesium hydroxide, a laxative. In addition, children with this condition are NPO and should not receive anything by mouth. D. During surgical intervention, the provider will remove the nonviable portion of the bowel so the bowel is anastomosed; there is no need for a colostomy.
A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse perform? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter
Correct Answers: A. Identify how much cleaner was in the bottle D. Insert an IV for morphine administration E. Apply a pulse oximeter The nurse should ask the parent or guardian about the size of the container, its contents prior to ingestion, and its contents remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should administer morphine as prescribed via IV to provide pain relief. The child is also at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level will help the nurse recognize if the child's airway is becoming obscured. Incorrect Answers: B. Activated charcoal is contraindicated for the treatment of poisoning with a corrosive agent because these substances can burn tissue, which the charcoal could then infiltrate. C. Gastric lavage is contraindicated for the treatment of poisoning with a corrosive agent because this could re-expose the upper gastrointestinal system to the corrosive substance, which can result in further injury.
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."
D. "You will be able to participate in physical exercises." Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. Incorrect Answers: A. Passive range-of-motion exercises are not done after a bleeding episode because rebleeding can occur. Active motion is best to allow activity to be tailored to the child's pain level. B. A manifestation of hemophilia A is hemarthrosis (bleeding into a joint capsule). This can result in numbness, tingling, or pain, along with discoloration, warmth, and swelling of the affected joint. The nurse should instruct the child to rest the joint, elevate it above the level of the heart, and apply ice to decrease the rate of bleeding into the joint capsule. C. Intracranial hemorrhage is a leading cause of death in clients who have hemophilia A. The nurse should instruct the child to avoid the use of aspirin because it has antiplatelet properties that can increase bleeding.
A nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No further treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."
D. "You will need to increase the dosage as your child gains weight." Epinephrine is a weight-based medication that is available in dosages of 0.15 mg and 0.3 mg. As the child grows, it will be necessary to change the epinephrine dosage that is administered. Incorrect Answers: A. Injectable epinephrine is an intramuscular injection administered into the vastus lateralis muscle of the child's thigh. B. Oral immunotherapy might be attempted with a child who has had an anaphylactic reaction to a food product. This therapy involves the administration of minute amounts of the allergen to increase tolerance to the food. However, this is only done under medical supervision. The parents should avoid administering peanut products to the child and should only use the epinephrine when an allergic reaction occurs. C. The nurse should instruct the parents to notify emergency services following the administration of epinephrine because the child might experience a delayed reaction even if the epinephrine has been administered. This delayed reaction can result in respiratory or cardiac arrest.
A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience
D. Encourage the child to focus on a recent pleasurable experience The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques. Incorrect Answers: A. The nurse should ask the child to find different designs in a kaleidoscope when using the nonpharmacological technique of distraction. B. The nurse should encourage the child to take a deep breath and let their body go limp during exhalation when using the nonpharmacological technique of relaxation. C. The nurse should encourage the child to think about a stop sign when beginning to feel pain when using the nonpharmacological technique of thought-stopping.
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis
D. Metabolic acidosis Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure.
