1. Which steps are correct in cleaning a wound using sterile technique? Select 3 correct answers. A. Clean the wound from top to bottom B. At the very
... [Show More] least a nurse should wear a mask, glasses, and an apron when doing a sterile dressing change C. Place the used gauze in the sharps contained D. Use a gauze for each wipe E. Clean the wound from the outside to the center F. Assess wound dressing at least once a shift 2. Please place the labs in the correct order of draw. A. Blood cultures B. Light blue top C. Red top D. Gold top E. Light green top F. Dark green top G. Lavender top H. ACD solution 3. Which one of the following findings should the nurse document as normal when measuring the vital signs of a 1-year-old? A. Axillary temperature of 100.9 F B. Respiratory rate of 20 C. Pulse of 112 bpm D. Femoral pulses graded at +1 4. Which of the following statements about temperature measurement in children is true? A. Glass mercury thermometers are recommended for accuracy in axillary measurements B. The axillary site is recommended by the American Academy of Pediatrics C. A rectal temperature should be taken in a newborn to check for a patent anus D. Rectal site is preferred in children under 1 month of age. 5. A nurse placed an NG tube in a patient without much difficulty. The patient calls the nurse back to the room and reports that the NG tube now has a scant amount of pink sputum in it. How should the nurse respond? A. Complete an abdominal assessment B. Remove the NG tube immediately and notify the provider C. Notify the provider and obtain an order for x-ray D. Reassure patient that this is not concerning and explain why 6. Which one of the following is an acute manifestation of pain in the neonate? A. Decreased muscle tone and increased vagal nerve tone contact: royfields212@gmail.com B. Increased transcutaneous oxygen saturation C. Increased heart rate; rapid and shallow respirations D. Increased skin dryness, decreased blood pressure, hyperglycemia 7. The most common side effect of opioid therapy is A. Pruritis B. Respiratory depression C. Nausea and vomiting D. Constipation 8. Communication with children must reflect their developmental thought process. Match each developmental stage with the communication guidelines important at that stage. A. Infancy- children in this stage primarily use and respond to nonverbal communication such as crying and cuddling B. Early childhood- focus communication on the child; experiences of others are of no interest to this child C. School-age years- children in this stage require explanations and reasons why this procedure is being done, yet are not fully able to understand D. Adolescence- children in this stage are often willing to discuss their concern with an adult not in the family 9. The nurse should obtain the vital signs of an infant in what order? A. Measure temperature, then count the pulse, and then count respirations. B. Measure temperature, then respirations, and then the pulse. C. Count the pulse, then respirations, and then the measure temperature. D. Count respirations, then the pulse, and then measure temperature. 10. In regard to pain management and children, nurses tend to: A. Overestimate the existence of pain in children undergoing procedures B. Overtreat children’s pain C. Realize that children are more likely to become addicted with opiate analgesics D. Undertreat children’s pain 11. Which position should a patient be placed when removing an NG tube? A. Supine position B. 30- to 45- degree position C. 30- to 50 – mL D. 90 degree position 12. Which one of the following has been shown to have calming and pain-relieving effects when used with invasive procedures in neonates such as circumcision? A. Allowing parent to hold neonate during procedure B. Administering of concentrated sucrose with and without non-nutritive sucking before the procedure C. Using relaxation techniques during the procedure D. Allowing neonate quiet time in the bassinet before the procedure 1. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with another nonsurgical client B. A room in the ICU C. A room that is within view of the nurses’ station D. A room with air exhaust directly to the outdoor environment 2. A 21-month-old child admitted with a diagnosis of croup now has a respiratory rate of 48 breaths/minute, a heart rate of 120 beats/minute, and a temperature of 100.8F tympanic. The child is inconsolable by the nurse or her parents. Which of the following should the nurse do next? A. Notify the physician immediately B. Allow the toddle to continue to cry C. Administer acetaminophen D. Offer clear fluids every few minutes. 3. The nurse is examining a 5-year-old boy. Which of the following signs or symptoms is a reliable early indication of respiratory illness in children? A. Rapid, shallow breathing B. Slow, irregular breathing C. Lethargy and listlessness D. A bluish tinge to the lips 4. Which of the following are appropriate ways to normalize hospitalization? A. Allow friends and visitors as often as possible B. Maintain bed rest for child as much as possible C. Promote dependence of the caregiver on the nurse as much as possible D. Maintain child’s routine if possible E. Promote the completion of school work as much as possible 5. The nurse is assessing the Babinski reflex on a 10 month old. Which of the following is a normal sign? A. Flexion of the toes B. Asymmetrical hyperextension of the toes C. Hyperextension of the toes D. Absence of hyperextension or flexion of the toes 6. Which is an example of primary prevention? A. Lead screenings B. Sanitation measures C. Education programs for children who are visually impaired D. A sick child visit to pediatrician 7. By the age of 2, the toddle generally: A. Is unable to learn correct terms for body parts B. Has clear body boundaries C. Recognizes gender differences D. Participates willingly in most procedures 8. A 12-month old is brought in for a well infant exam. The nurse knows that the best approach to the physical examination for this patient will be to: A. Completely undress the infant and leave him undressed during the exam B. Have the infant sit on the parent’s lap to complete as much of the exam as possible C. Perform an examination in a head to toe direction D. Place the infant on the exam table with the parent out of view 9. What is one indication that dornase alfa (Pulmozyme) has been therapeutic of a patient with cystic fibrosis? A. Increased incidence of cough, rhinitis, and rash B. Decreased pulmonary function within 48 hours of discontinuation of the medicine C. Decreased infection rates D. Increased need for antibiotic therapy 10. When introducing new food, the parents should not: A. Offer the new food by itself at first B. Mix food with formula to feed through a nipple C. Decrease the quantity of the infant’s milk D. Introduce new foods in small amounts 11. The nurse is examining an 8-year-old boy with tachycardia and tachypnea. Which one of these noninvasive tests can determine the extent of the hypoxia? A. Pulse oximetry B. Chest x-ray C. Pulmonary function test D. Arterial blood gases 12. Which of the following assessment findings would be considered most worrisome and abnormal? A. Begins to roll from front to back at 5 months of age B. Takes the first step after 24 months of age C. Begins to sit unsupported at 9 months of age D. Displays head lag at 3 months of age 13. The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a muffled whisper, and sits up with her neck thrust forward. Based on these findings, which of the following actions must the nurse avoid? A. Providing 100% oxygen B. Visualizing the throat C. Auscultating for lung sounds D. Making the child sit up 14. A twelve-year-old with asthma wants to exercise. Which of the following activities should the nurse suggest? a. Soccer b. Baseball c. Swimming d. Gymnastics 15. The parent of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the parent do? A. Keep the child in a low-humidity environment B. Offer extra fluid frequently C. Count the child’s respiratory rate every 30 minutes D. Bring the child to the clinic immediately 16. Match the recommendation to safety concern: A. Avoid leaving bottles with infant overnight- Can result in caries B. Put baby on their back to sleep- can prevent SIDS C. Know the safest place to put a car seat- can prevent this number one cause of death D. Do not leave unguarded on an elevated surface- can prevent this number one injury 17. An 11-year-old is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed? A. Productive cough B. Respiratory rate of 20 breaths per minute C. Intercostal retractions D. Thin, copious mucous secretions 18. Of the following techniques, which is the best to use when toilet training a toddler? A. Ensure the toddler’s privacy during the sessions B. Place the potty chair near a television to help distract the child during sessions C. Remove the child form the bathroom to flush the toilet D. Limit sessions to 5-10 minutes of practice 19. An infant has diaper dermatitis. Select the 4 interventions the nurse needs to be perform. A. Rub and wash skin in the area vigorously to increase circulation B. Use topical steroids if preventative tactics do not work C. Use only wipes that contain alcohol D. Use medications to treat infections if indicated E. Use barrier creams/ointments F. Aim at prevention through teaching 20. Which finding can be a sign of possible Autism? A. Lack of imitation such as playing peekaboo at a developmentally appropriate age B. Inability to speak 3-5 words by 7 months C. Overly gregarious in social interactions D. Lack of mobility by (crawling, walking) 1 year 21. The nurse is assessing 7-year-old boy with pharyngitis. Which of the following symptoms would be least likely to be observed? A. Difficulty swallowing B. Rash on the abdomen C. Vomiting D. Sore throat and headache 22. While the nurse is working in a homeless shelter, assessment of a 6-month-old infant reveals a respiratory rate of 52 breaths/minute, retractions, and wheezing. Which of the following actions would be most appropriate? A. Send the infant for a chest x-ray B. Administer a nebulizer treatment C. Refer the infant to the emergency department via ambulance D. Provide teaching about cold care to the mother 23. The purpose of nonnutritive sucking is to: A. Provide an efficient way to process fluids B. Take in food C. Collect food and propel it into the esophagus D. Satisfy the basic sucking urge and offer comfort 24. Using Erikson’s theory as a foundation, the primary developmental task of the toddler period is to: A. Achieve a sense of accomplishment B. Learn to give up dependence for independence C. Satisfy the need for basic trust D. Acquire language or mental symbolism 25. The nurse can expect that an infant will respond to the sound of a human voice by vocalizing at: A. 10 months of age B. 8 months of age C. 12 months of age D. 2 months of age 26. Separation anxiety and stranger gear normally begin to appear by: A. 6 months B. 14 months C. 4 weeks D. 16 months 27. A 12-year-old child with asthma is receiving albuterol nebulizer treatments. The patient is very irritable. Her heart rate has increased from 90 beats/minute to 120 beats/minute. The nurse should: A. Administer oxygen to decrease the heart rate B. Check the oxygen saturations and administer another nebulizer treatment if the sats are less than 95% C. Inform the primary health care provider that the child is having an allergic reaction to the medicine D. Hold the next dose of albuterol and inform the physician of the child’s pulse rate changes 28. Which illnesses are the most common in toddlers. Select 3 answers. A. Food allergies B. Pneumonia C. Tonsillitis D. Otitis media E. Upper respiratory infections 1. The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day? A. 1,600 mL B. 1,700 mL C. 1,560 mL D. 1,650 mL 2. The nurse is taking a health history of an 11-year-old girl with recurrent abdominal pain. Which of the following responses would indicate irritable bowel syndrome? A. “the pain does not wake me up in the middle of the night.” B. “I don’t take any medicine right now.” C. “The pain comes and goes.” D. “I always feel better after I have a bowel movement.” 3. Which of the following is a clinical manifestation of increased intracranial pressure (ICP) in children? A. Diplopia, blurred vision B. Sunken fontanel C. Increased blood pressure D. Low-pitched cry 4. Which of the following terms is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? A. Persistent vegetative state B. Stupor C. Coma D. Obtundation 5. The nurse is conducting a physical examination of a child with suspected Crohn’s disease. Which of the following findings would be the most highly specific for Crohn’s disease? A. Normal growth patterns B. Poor growth patterns, along with perianal fissures C. Abdominal tenderness D. Frothy stools 6. The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. Which of the following would the nurse include in the teaching plan? A. Creamed spinach B. Rye bread C. Frozen yogurt D. Fruit juice 7. In a child with intussusception, the nurse would describe the stools as: A. Clay-colored B. Currant jelly-like C. Green, watery D. Greasy 8. The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which of the following approaches would most likely elicit the child’s cooperation? A. “if you don’t try, I will have to get the doctor.” B. “You must blow in this or you might get pneumonia.” C. “Can you cough for me please?” D. “Can you blow this cotton ball across the tray?” 9. The physician has ordered rectal diazepam (Valium) for a 2-year-old boy with status epilepticus. Which of the following is the most essential intervention? A. Monitor for an allergic reaction to the medication B. Monitor the level of sedation and the respiratory rate C. Gradually reduce the dose of medication D. Watch for a temperature elevation indicating infection 10. A 4-year-old boy has a febrile seizure during a well-child visit. Which of the following is the priority nursing intervention? A. Loosen the child’s clothing to ensure a patent airway and place something in his mouth B. Protect the child from harm during the seizure and continually monitor airway status C. Place the child on his back with his head hyperextended when the seizure ends D. Place the child on his side and apply physical restraints during the seizure 1. A nurse is assessing an adolescent who has an exacerbation of Graves’ disease. Which of the following findings should the nurse expect? A. Heat intolerance B. Bradycardia C. Weight gain D. Lethargy 2. Which of the following accurately describes the expected cognitive development during the concrete operations period of middle childhood? A. Children are able to use their thought processes to experience events and actions and make judgments based on what they reason B. Children progress from conceptual thinking to perceptual thinking when making judgments C. Children are able to view from an egocentric outlook that is rigidly developed around the action to be completed D. Children are able to follow directions but not verbalize the actions involved in the process 3. A nurse is participating in lead screening at a community center. The nurse should instruct parents to bring their children back for a rescreening in a year for which of the following laboratory values? A. 4 mcg/dL B. 18 mcg/dL C. 44 mcg/dL D. 10 mcg/dL 4. The nurse plans to conduct a sex education class for 10-year-olds. Which of the following does the nurse recognize as most appropriate for this age group? A. Present sex information as a normal part of growth and development B. Segregate boys and girls and include info related only to the gender present at the discussion C. Discourage question and answer sessions D. Since sexual info supplied by the parents usually produces feelings of guilt and anxiety in children, avoid parental assistance in conducting the program. 5. According to Erikson, what is the developmental goal of middle childhood (5-12)? A. Trust B. Autonomy C. Industry D. Initiative 6. During the adolescent health screening interview, the nurse will focus on which of the following to best address injury prevention? A. Motor vehicle crashes B. Burns C. Drowning’s D. Drug use 7. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? A. Inject insulin in the deltoid muscle B. Take PO glyburide with breakfast C. Obtain an influenza vaccine annually D. Administer glucagon for hyperglycemia 8. Jim, a 13-year-old, is sent to the school nurse because he and his peers were caught chewing tobacco while playing baseball. The nurse knows that the best way to influence Jim’s behavior for health promotion would be which of the following? A. Arrange for a local baseball hero to talk with Jim and his friends, stressing that he doesn’t use chewing tobacco, his friends do not chew tobacco, and that it causes ugly teeth B. Show Jim pictures of oral cancers from chewing tobacco C. Tell Jim about the dangers of chewing tobacco and stress the fact that girls do not like boys who chew tobacco D. Tell Jim that he will be suspended from school if he continues to chew tobacco. 9. A 7-year-old was caught taking a classmate’s toy. Which of the following is an important understanding of this behavior? A. The child will learn the importance of respecting other’s property if the parents unexpectedly give away one of the child’s toys B. This stealing act is an indication that something is seriously lacking in this child’s life C. At this age, the child’s sense of property rights is limited, and the child took the items simply because they wanted it D. If the child is caught and punished and promises not to do it again, the child will keep that promise. 10. A nurse in the ER is caring for an adolescent following a suicide attempt. After reviewing the client’s history, the nurse should determine that which of the following is the priority risk factor for suicide completion? A. Loss of a parent B. Previous suicide attempt C. History of substance abuse D. Active psychiatric disorder 11. Even with good glucose control, a child with type 1 diabetes may frequently encounter the acute complication of: A. Hyperosmolar nonketotic coma B. Hypoglycemia C. Ketoacidosis D. Retinopathy 12. A nurse is assessing a school-aged child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect? A. Tremors B. Pallor C. Lethargy D. Shallow respirations 13. A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? Assume that the child is up to date on all of his/her vaccines except the 12 month vaccines. A. Measles, mumps rubella (MMR) B. Diphtheria, tetanus, and acellular pertussis (DTaP) C. Rotavirus (RV) D. Human papillomavirus (HPV4) E. Varicella (VAR) 14. A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction? A. “I will report a change in her breathing or any signs of confusion.” B. “I will continue to check his blood sugar two times every day” C. “I will encourage her to drink half a cup of water or sugar-free fluids every 30 minutes” D. “I will notify the doctor if her temperature is not controlled with acetaminophen” 15. A nurse is caring for a child who has Addison’s disease. Which of the following actions should the nurse take? A. Monitor the child for fluid volume excess B. Discuss the manifestations of hypoglycemia with the parents C. Teach the parents about cortisol replacement therapy D. Place the child on a low-sodium diet 16. A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent’s blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? A. Deep, rapid respirations B. Polyuria C. Tachycardia D. Dry, flushed skin 17. A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A. A story book about a child who has diabetes B. A needleless syringe and a doll C. A video game D. A period of play in the playroom 18. A school nurse identifies that a child has pediculosis capitis and educates the child’s parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. “All recently used clothing, bedding, and towels must be washed in hot water” B. “I will treat all the family members to be on the safe side” C. “Toys that can’t be dry cleaned or washed must be thrown out” D. “My child must be free from nits before returning to school” 19. An early sign of diabetes mellitus in the adolescent would be: A. Kussmaul respirations B. All answers are correct C. A vaginal candida infection D. Obesity 20. The moral and spiritual development of the preschooler is characterized by: A. Concern for why something is wrong B. Actions that are directed toward satisfying the needs of others C. A very concrete sense of justice D. Thoughts of loyalty and gratitude 1. Of the following assessment findings, the one that would most likely be seen in a child with leukemia is: A. Bruising, nosebleeds, paleness, and fatigue B. Wheezing and shortness of breath C. Abdominal swelling D. Weakness of the eye muscle 2. When discussing hemophilia with the parents of a child recently diagnosed with this disease, the nurse tells the parents that: A. All of the daughters of the parents will be carriers B. Each of their sons has a 75% chance of being affected C. Hemophilia is an x-linked disorder in which the mother is carrier of the illness but is not affected by it D. Hemophilia is a recessive disorder carried by either the mother or the father 3. A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Hyporeflexia B. Negative Babinski reflex C. Increased appetite D. Tachycardia 4. A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication? A. Administer at bedtime B. Administer at mealtimes C. Give with orange juice D. Give with a 240 mL (8 oz) glass of milk 5. A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions? A. Talking to the client at the bedside B. Completing a dressing change C. Administering an IM injection D. Administering an intermittent IV bolus medication 6. Dental care for a child with cancer whose platelet count is 32,000/mm3 and granulocyte count is 450/mm3 should include daily: A. Use of an electric toothbrush B. Toothbrushing with flossing C. Use of an alcohol-based mouthwash D. Wiping with moistened sponges or a very soft-bristled toothbrush 7. A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms? A. Fungal and bacterial infections B. Kaposi’s sarcoma C. Pneumocystis lung infection D. Flu-like symptoms and night sweats 8. Which of the following are communication techniques recommended when talking to a family about the death of a child? Select two correct answers. A. Allow silence and tears B. Realized that the family already knows what is happening or will happen (Child’s death) C. Identify what is important to the family now D. Choose your words that are “softer” such as using the phrase “passing away” 9. Neuroblastoma is often classified as a silent tumor because: A. The primary site is the bone marrow B. Diagnosis is not usually made after metastasis C. Diagnosis is made based on the location of the primary site D. The primary site is intracranial 10. A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral condition? A. Candidiasis B. Xerostomia C. Halitosis D. Gingivitis 11. In developing a plan of care for a child with sickle cell anemia who is admitted with knee and back pain and is diagnosed with vasoocclusive crisis, the nurse knows that they pain is due to which of the following? A. Shorter life span of the RBCs and the fact that the bone marrow can’t produce enough RBCs B. Pooling of large amounts of blood in the liver and spleen C. Tissue anoxia brought on by the sickle cells occluding blood vessels D. RBC destruction related to a viral infection or transfusion reaction 12. A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching? A. “Our child’s blood count will need to be monitored routinely for several weeks” B. “The medication will be more effective if it is administered with meals” C. “Restricting fiber from our child’s diet will help absorption of the iron” D. “The medication should be administered in one large dose every day” 13. A child is admitted with a suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the following warnings over the child’s bed? A. No venipuncture or blood pressure in left arm B. Do not palpate abdomen C. Contact precautions D. Collect all urine in as a 24 hour specimen 14. A 7-year-old boy is receiving a transfusion of packed red blood cells. After 45 minutes, he reports chills, tightness in his chest, and a headache. The priority action of the nure is to: A. Slow the transfusion and send a sample of the patient’s blood and urine to the lab for analysis B. Stop the transfusion, maintain a patent IV live with normal saline and new tubing, and notify the practitioner. C. Stop the transfusion, maintain a patent IV line with normal saline and new tubing, and administer acetaminophen. D. Slow the transfusion rate until the symptoms subside, listening to the lungs for crackles 15. Disseminated intravascular coagulation is: A. A secondary disorder characterized by bleeding and clotting, which occur simultaneously B. Characterized by an increased tendency to form clots, along with diagnostic findings that include low prothrombin levels and increased fibrinogen levels C. A primary disease characterized by abnormal coagulation D. Treated with blood transfusion of whole blood and factor VIII concentrate 16. A candidate for bone marrow transplant is the child who: A. Has acute leukemia B. Has a compatible donor in his or her family C. Has chronic leukemia D. Is unlikely to be cured by other means 17. A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect A. High fever B. Constipation C. Bradycardia D. Pain 18. Leukemia is characterized by: A. A high leukocyte count B. Destruction of normal cells by abnormal cells C. Low numbers of blast cells D. Overproduction of white blood cells 19. A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for which of the following adverse effects of this medication? A. Cardiac dysrhythmia B. Aplastic anemia C. Renal failure D. Metabolic alkalosis 20. The severe cellular damage that is caused by chemotherapy drugs infiltrating into surrounding tissue occurs when the chemotherapeutic agent is a(n): A. Steroid B. Antimetabolite C. Vesicant D. Hormone [Show Less]