Final Exam Questions

The nurse is preparing to perform an assessment on a toddler hospitalized for dehydration. Place the following steps in order from what the nurse would perform first to last when assessing the child.

1. Observe the child's skin color and general appearance 2. Count the respiratory rate 3. Obtain the apical heart rate 4. Unfasten the child's diaper to view the perineal area and buttocks

A school-age client diagnosed with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention is a priority for this client? a. Reposition the child every hour. b. Encourage fluids. c. Monitor respiratory rate every hour. d. Limit visitors.

a. Reposition the child every hour.

The nurse is providing education at a community child safety event. For each age group, match the most likely teaching topic for the parents to prevent injury.

Schoolage - helmet safety Infant - safe sleep practices Preschooler - stranger danger Adolescent - safe texting practices while driving Toddler - drowning

The nurse is developing a health promotion brochure for parents regarding urinary tract infections in children and teens. Which of the following should the nurse include in the brochure? Select all that apply. a. Teens need to void immediately after sexual intercourse. b. Taking showers decreases the risk of infection. c. Children should avoid scented and colored toilet paper. d. Bubble baths decrease the risk of infection. e. Children should wipe the perineal area front to back. f. Children should wear nylon underpants.

a. Teens need to void immediately after sexual intercourse. b. Taking showers decreases the risk of infection. c. Children should avoid scented and colored toilet paper. e. Children should wipe the perineal area front to back.

The nurse is caring for a 2 year old admitted with gastroenteritis. After treatment, which of the following indicate to the nurse that treatment has been effective? a. 0.5 mL/kg/hour b. 2 mL/kg/hour c. 10 mL/kg/hour d. 5 mL/kg/hour

b. 2 mL/kg/hour

The nurse in the clinical is teaching a teenager how to wear a brace for the correction of scoliosis. Which of the following nursing diagnoses would the nurse identify as the priority? a. Altered growth and development, risk for b. Impaired skin integrity, risk for c. Impaired gas exchange d. Impaired mobility, risk for

b. Impaired skin integrity, risk for

The nurse is caring for a child with cerebral palsy. Which of the following statements is correct when the nurse is discussing the diagnosis with the parents? a. "Cerebral palsy is the result of injury to the sensory area of the brain." b. "Brain surgery commonly helps or even cures children with cerebral palsy." c. "Cerebral palsy is a non-progressive disease caused by damage to the brain." d. "Physical therapy is of little value to a child with cerebral palsy."

c. "Cerebral palsy is a non-progressive disease caused by damage to the brain."

The nurse in the outpatient clinic is performing a well-child visit on an immunocompromised child. Which of the following immunizations is contraindicated for this child? a. Hepatitis B b. HPV c. Influenza d. Varicella

d. Varicella

The nurse in the outpatient clinic performs and assessment and notes an enlarged lymph node. The child tells the nurse he has been experiencing weight loss and night sweats. Which of the following diagnosis does the nurse suspect? a. Hodgkin's lymphoma b. Rhabdomyoscarcoma c. Leukemia d. Non-hodgkin's lymphoma

a. Hodgkin's lymphoma

A child is scheduled for a kidney transplant. The nurse completes the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. Which statement by the parents indicates understanding of the teaching session? a. "We'll be glad are child is cured and will no longer need special treatments." b. "We know it's important to see that our child takes prescribed medications after the transplant." c. "It is a relief that our child won't have to be as careful to prevent catching colds from other children at school." d. "We're happy our child won't have to take any more medicine after the transplant."

b. "We know it's important to see that our child takes prescribed medications after the transplant."

A child is diagnosed with group A beta-hemolytic streptococcus infection of the throat. Which is the priority to include in the teaching plan? a. Keep the child NPO (nothing by mouth). b. Administer the entire course of antibiotics to the child. c. Restrict the child's interaction with other children until the antibiotic is complete. d. Gargle with an alcohol-based mouthwash.

b. Administer the entire course of antibiotics to the child.

A nurse on the pediatric unit has been assigned four clients. Which task should the nurse complete first? a. Engage a toddler in play b. Check the placement of elbow restraints for an infant status-post cleft palate repair c. Wash the hair of a teen who reports extreme fatigue and is scheduled for radiation therapy for treatment of Hodgkin lymphoma d. Collect a stool specimen for ova and parasites from a school-age child who has diarrhea

b. Check the placement of elbow restraints for an infant status-post cleft palate repair

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace . Which statement by the parents indicates a need for further instruction? a. I will have my child wear soft fabric clothing under the brace b. I should apply lotion under the brace to prevent skin breakdown c. I will encourage my child to perform prescribed exercises d. I should avoid the use of powders under the brace

b. I should apply lotion under the brace to prevent skin breakdown

The nurse is caring for the child admitted with a mass in the upper right quadrant, vomiting, and the passage of stools with blood and mucus. Which of the following medical conditions does the nurse expected in the child's medical record? a. Gastroesophageal reflux b. Intussusception c. Hirschsprung's disease d. Tracheoesophageal fistula

b. Intussusception

The nurse in the emergency department admits a school-aged child who fell over the handlebars of his bike. The child is unconscious. Which of the following is the priority nursing intervention for this child? a. Provide emotional support to the parents b. Maintain a patent airway c. Insert a nasogastric tube d. Obtain intravenous access

b. Maintain a patent airway

The nurse is caring for a child receiving peritoneal dialysis. Which of the following complications is the child at risk for developing? a. Seizures b. Hypovolemia c. Peritonitis d. Oliguria

c. Peritonitis

The nurse is providing teaching to the parents of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parents requires further teaching? a. "My child should use a straw to take the medication." b. "My child may experience constipation." c. "My child should drink citrus juice when taking the medication." d. "My should should drink milk when taking the medication."

d. "My should should drink milk when taking the medication."

A child is being discharged after surgery for a myelomeningocele repair. Before discharge, the nurse works with the parents to establish a catheterization schedule to prevent urinary tract infection. With what frequency should the nurse instruct the parents to catheterize the child? a. Every 6-8 hours b. Every 10-12 hours c. Every hour d. Every 3-4 hours

d. Every 3-4 hours

The nurse is caring for an infant in pain after a surgical procedure. Which of the following is an appropriate nursing intervention for this child? a. Place the child in a swing at the nurse's station b. Play classical music in the room c. Position the infant on her abdomen with the head of bed elevated d. Rocking the infant with his/her favorite blanket

d. Rocking the infant with his/her favorite blanket

A 12-year-old girl is noted to walk with an uneven gait, and her shoulders appear uneven. The left shoulder sits lower than the right shoulder, and her waist appears to be tilted from side to side. Which condition is the girl most likely experiencing? a. Hip dysplasia b. Internal femoral torsion c. Club foot d. Scoliosis

d. Scoliosis

The nurse is providing teaching to the parents of an infant admitted for surgical repair of hypospadias. Which of the following statements should the nurse include in the teaching? a. Place a barrier cream in the diaper area to protect the incision site. b. Cover the penis with clear plastic wrap to prevent the surgical site from becoming contaminated with stool. c. Wait 72 hours before giving your son a tub bath. d. Use the double diapering technique until the stent is removed.

d. Use the double diapering technique until the stent is removed.

The nurse is caring for a child with a brain tumor. Which of the following clinical manifestations would the nurse expect to observe? a. Hypotension b. Diarrhea c. Abdominal pain d. Vomiting

d. Vomiting

A child undergoing chemotherapeutic treatment for cancer is being admitted to the hospital for a fever of 102 degrees F and possible sepsis. Cultures, antibiotics, and acetaminophen along with bed rest have been ordered for this child. Place the following steps in order from first to last. - Obtain the cultures. - Administer the acetaminophen. - Administer the antibiotic. - Reassure the parents about the plan of care during hospitalization.

- Administer the acetaminophen - Obtain the cultures - Administer the antibiotics - Ensure the child has bed rest

The nurse is caring for a school-aged child who has recently began having episodes of enuresis. The nurse suspects the child has recently developed which of the following? a. Emotional distress b. Constipation c. Urinary tract infection d. Potty training

a. Emotional distress

A pediatric nurse is triaging children in the emergency department. Which child should the nurse ask the provider to care for first? a. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min b. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication c. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge d. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

d. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough

The nurse is providing care to a male infant who has been diagnosed with hypospadias. Which of the following clinical manifestations does the nurse expect to observe when assessing the infant? a. A urethral meatus that is located on the ventral side of the penis. b. A small opening or fissure that extends the entire length of the penis. c. A urethral meatus that is located on the dorsal surface of the penis. d. A sac protruding from the lower abdomen containing the bladder.

a. A urethral meatus that is located on the ventral side of the penis.

A parent tells the nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should teach the parent that the toddler is at risk for developing which of the following conditions? a. Iron deficiency anemia b. Diabetes c. Obesity d. Rickets

a. Iron deficiency anemia

The elementary school nurse is promoting nutrition for the school-age population at the health fair. Which of the following is the most common nutrition concern in this age group? a. Obesity b. Physiological anorexia c. Caffeine addiction d. Eating disorders

a. Obesity

The nurse is caring for a child who has been sedated for a lumbar puncture. Which nursing intervention is the priority for this child? a. Place the child on a cardiac monitor. b. Allow parents to stay with the child. c. Assess the child's respiratory rate. d. Elevate the head of the bed.

c. Assess the child's respiratory rate.

A toddler is in end-stage renal failure. Which nursing intervention is the most appropriate for this child? a. Maintain the child's normal routines. b. Promote the child to ask questions about the illness. c. Encourage friends to visit. d. Explain body changes that will take place.

a. Maintain the child's normal routines.

The nurse is teaching the parents of an infant about the transition from breast milk or formula to solid foods during infancy. Which of the following information should the nurse provide to the parents? a. Once solid foods are introduced, they should be introduced one at a time, every 3-4 days. b. Solid foods should not be introduced until 8-10 months. c. Fruits and vegetables should be introduced first. d. Solid foods should be mixed in a bottle to make the transition easier for the infant.

a. Once solid foods are introduced, they should be introduced one at a time, every 3-4 days.

A nurse caring for a school-age client notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which of the following is the priority to assess for this child? a. Nausea b. Respiratory rate c. Urine output d. Skin integrity

b. Respiratory rate

The nurse is caring for a newborn with hyperbilirubinemia. Which of the following nursing problem statements should the nurse develop into a nursing diagnosis and include in the plan of care? Select all that apply. a. Risk for infection b. Risk for imbalanced body temperature c. Risk for injury d. Risk for ineffective airway clearance e. Risk for fluid volume deficit f. Risk for ineffective infant feeding pattern

b. Risk for imbalanced body temperature c. Risk for injury d. Risk for ineffective airway clearance f. Risk for ineffective infant feeding pattern

An 8-year-old child arrives at the emergency department with fever. The child has been receiving chemotherapy for treatment of leukemia . Which intervention should the nurse implement first? a. Prepare the child for a bone marrow aspiration. b. Set up neutropenic precautions for the child. c. Complete a thorough physical assessment. d. Draw blood work for a CBC and blood culture.

b. Set up neutropenic precautions for the child.

The nurse is caring for a child who reports he has pain in his ankle after "twisting" it while playing. Which of the following would be the priority follow-up assessment? a. Palpation of the joints proximal to the ankle b. Swelling and deformity of the ankle joint c. The patient's gait and range-of-motion of all extremities d. Color and temperature of the skin around the ankle

b. Swelling and deformity of the ankle joint

The nurse in the urgent care clinic has four patients. Which of the following patients should the nurse see first? a. 2-year-old with temperature of 100.8 degrees Fahrenheit b. Toddler with a heart rate of 125 bpm c. 1-year-old crying and inconsolable d. Infant with a respiratory rate of 48 breaths per minute

c. 1-year-old crying and inconsolable

The nurse is planning care for a 10 month old infant who is 8 hours postoperative following a cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? a. Keep the infant supine. b. Offer formula through a sippy cup. c. Apply and release elbow restraints every hour. d. Suction the mouth with the appropriate sized catheter.

c. Apply and release elbow restraints every hour.

A newborn is diagnosed with Hirschsprung disease. Which of the following assessment findings would the child exhibit? a. Projectile vomiting; altered electrolytes b. Currant jelly stools; pain c. Failure to pass meconium; abdominal distension d. Acute diarrhea; dehydration

c. Failure to pass meconium; abdominal distension

The nurse is planning care for a preschooler who has been diagnosed with juvenile idiopathic arthritis. Which of the following is the most important nursing intervention for this child? a. Decrease the temperature in the room. b. Apply cool compresses for 20 minutes every hour. c. Identify the physical activities the child plays at daycare and at home. d. Schedule prolonged periods of joint immobilization daily.

c. Identify the physical activities the child plays at daycare and at home.

The nurse in the outpatient clinic performs and assessment and notes several bruises. The child tells the nurse he has been experiencing weight loss and has been more tired than usual. Which of the following diagnosis does the nurse suspect? a. Non-hodgkin's lymphoma b. Hodgkin's lymphoma c. Leukemia d. Rhabdomyoscarcoma

c. Leukemia

The nurse is caring for a child diagnosed with glomerulonephritis. The child is in the playroom and experiences blurred vision and a headache. Which action by the nurse is the priority? a. Document the findings in the medical record. b. Check the urine to see if hematuria has increased. c. Obtain a blood pressure on the child. d. Reassure the child and encourage bed rest.

c. Obtain a blood pressure on the child.

A school-age client who has autism is admitted to the hospital for treatment of dehydration due to vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission? a. Take the child to the playroom immediately for arts and crafts. b. Admit the child in a room near the nurse's station. c. Orient the child to the hospital room and minimal environmental distractions. d. Take the child on a quick tour of the whole unit

c. Orient the child to the hospital room and minimal environmental distractions.

The nurse is caring for a child with a lower leg cast. The child tells the nurse the cast is rubbing the skin along the upper edge of the cast. Which of the following actions should the nurse take first? a. Notify the medical provider. b. Tell the parents to apply lotion to the irritated skin twice a day. c. Petal the edges of the cast with moleskin. d. Place pieces of sterile gauze between the skin and the cast.

c. Petal the edges of the cast with moleskin.

An adolescent client who is diagnosed with Duchenne muscular dystrophy is seen in the clinic for a routine health visit. Which of the following is the priority for this client? a. Risk for Altered Comfort b. Risk for Impaired Skin Integrity c. Risk for Aspiration d. Risk for Infection

c. Risk for Aspiration

A school-age child is transported to the emergency department by ambulance from the scene of a car accident. The client is alert and oriented × 3; pulse, respirations, and blood pressure are stable; and the neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The client states, "I can't feel or move my legs." Which injury does the nurse suspect? a. Ruptured spleen b. Traumatic brain injury c. Spinal cord injury d. Muscular dystrophy

c. Spinal cord injury

A three-week-old infant has just returned from a pyloromyotomy two hours ago. The father is refusing pain medication for the infant and states, "The baby is hungry. Can I give the baby a bottle?" How should the nurse best advocate for the infant? a. Administer the prescribed pain medication. b. Call the physician to ask if the child can feed yet. c. Assess for bowel sounds and if they are present allow the parent to feed the child. d. Educate the parent about the surgical complications and why the infant should not have anything by mouth at this time.

d. Educate the parent about the surgical complications and why the infant should not have anything by mouth at this time.

The nurse is caring for a child receiving chemotherapy experiencing severe nausea and vomiting. Which of the following nursing diagnosis is the highest priority for this child? a. Imbalanced nutrition, risk for b. Deficient fluid volume, risk for c. Body image disturbance, risk for d. Fluid and electrolyte imbalance, risk for

d. Fluid and electrolyte imbalance, risk for

The nurse is caring for a school-aged child with a fracture. Which of the following diet selections would be the most appropriate for this child? a. Hamburger and french fries b. Ham sandwich, chips and apple juice c. Eggs, sausage and orange juice d. Peanut butter sandwich, banana, and milk

d. Peanut butter sandwich, banana, and milk

The nurse is teaching a parent of a preschool child about factors that affect the child's perceptions of death. Which of the following should be included in the teaching? a. Preschoolers accept the permanence of death. b. Preschoolers fear death c. Preschoolers have no concept of death. d. Preschoolers perceive death as temporary.

d. Preschoolers perceive death as temporary.

The nurse is caring for a child that is not toilet trained. The primary health care provider has ordered the measurement of intake and output. Which of the following nursing interventions is the most appropriate method to assess output? a. Have the parents estimate the output. b. Place a urine specimen device on the child to collect each void. c. Place cotton balls in the diaper to absorb the urine and then measure after each diaper change. d. Weigh the diapers after each diaper change.

d. Weigh the diapers after each diaper change.

The nurse is providing care for a 9-year-old patient diagnosed with postinfectious glomerulonephritis. The nurse is aware of hypertension and a prescribed dose of nifedipine 0.5 mg/kg/dose every 4 hours. The patient weighs 63 pounds. Which dose does the nurse give every 4 hours?

14.3 mg

The nurse is caring for a child receiving peritoneal dialysis. The primary medical provider orders 1500 mL of dialysate solution to be infused three times a day. The fluid should dwell for 1 hour. After the first exchange, the nurse measures 1175 mL in the drainage reservoir. What value should the nurse document in the chart as intake after the first exchange? Do not put the units, just the numeric value.

325 mL

The nurse is providing care to a child with heart failure. Match each intervention to the appropriate goal of nursing care.

Decrease workload of the heart - cluster cares Promote adequate nutrition - gavage (tube) feeds Incerase tissue oxygenation - oxygen therapy Maintain fluid & electrolyte balance - administer diuretics

The experienced nurse is teaching a new graduate nurse about the differences between hyperglycemia and hypoglycemia. For each symptom, identify if it is a clinical manifestation of hypoglycemia or hyperglycemia.

Diaphoresis - Hypoglycemia Ketones - Hyperglycemia Rapid Respirations - Hyperglycemia Chills - Hypoglycemia

A nurse is caring for a child who has an older sibling diagnosed with terminal cancer. Match the child's concept of death with the appropriate behavioral response.

Infant - no understanding of death Toddler - Senses emotions of caregivers and altered routines Preschooler - Believes death is temporary and the person will return Schoolage - Understands the difference between temporary seperation and the permanence of death Adolescent - Capable of understanding concepts related to death and that all people and self will die

The nurse is the emergency department has been assigned to care for a toddler with hemophilia who fell down a few steps. Which of the following would be the priority assessment for this child? a. A headache b. Bruises on the arm c. A swollen knee d. Fear of strangers

a. A headache

An infant admitted with a bowel obstruction has been NPO for surgery for 3 hours and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which action by the nurse is the most appropriate? a. Call the primary provider to see if the infant needs to have an intravenous line started. b. Allow the mom to breastfeed the infant. c. Feed the infant 2 ounces of electrolyte rehydration solution. d. Reassure the parents that it will not be much longer before surgery.

a. Call the primary provider to see if the infant needs to have an intravenous line started.

The nurse in the outpatient clinic is caring for a toddler, while obtaining the health history the parent states that while bathing the child he/she noticed a mass in the child's abdomen and the child's urine is slightly pink in color. Which of the following is a priority intervention for this child? a. Instruct the parent to avoid pressing on the abdomen. b. Obtain a urine specimen for urinalysis. c. Determine if the child is having pain. d. Test the child's urine for blood.

a. Instruct the parent to avoid pressing on the abdomen.