Exam Review
- A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?A)Reposition the client using a turning sheet.B)Tighten the screws on the halo device one-quarter turn every 48 hr.C)Encourage flexion and extension of the neck.D)Assess the pin sites for infection once every other day.
- A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?A)Place the infant in a recumbent position during feeding.B)Allow the infant 45 min for each feeding.C)Allow the infant to self-soothe by crying prior to feeding.D)Implement a 3-hr feeding schedule.
- A nurse is evaluating the pain level of a toddler who is cognitively impaired to a non- pharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?A)FLACCB)Visual analogC)FACESD)CRIES
- A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?A)"Your child should walk the bicycle through intersections."B)"Your child should keep the bicycle at least 3 feet from the curb while riding in the street."C)"Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle."D)"Your child should ride the bicycle against the flow of traffic."
Exam Review
- A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?A)Establish a reward system.B)Hold the child during assessments.C)Maintain extended eye contact.D)Engage in cooperative play.
- A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?A)Apply pressure just above the insertion site.B)Monitor the pulse distal to the insertion site.C)Obtain vital signs.D)Reinforce the dressing.
- A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?A)Increase fluid intake to 2 L/day.B)Weigh the child once per day.C)Position the child supine at bed time.D)Limit calorie intake to 45 cal/kg/day.
- A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis? Select all that apply.(SATA)A)Blood urea nitrogen (BUN)B)Partial thromboplastin time (PTT)C)C-reactive protein (CRP)D)Antistreptolysin O (ASO) titerE)Erythrocyte sedimentation rate (ESR)
Exam Review
- A nurse is caring for a newly admitted child who has cystic fibrosis. For which of the following members of the interprofessional team should the nurse initiate a referral?A)DietitianB)Physical therapistC)Speech-language pathologistD)Occupational therapist
- A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?A)Doll's eye reflex intactB)No head lag when pulled to a sitting positionC)Positive Babinski reflexD)Presence of tears when crying
- A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?A)Secure the restraints with a quick-release knot.B)Assess the child every 4 hr while in restraints.C)Request that the provider renew the prescription for restraints every 48 hr.D)Tie the restraints to the side rails of the child's bed.
- A nurse is reviewing the complete blood count results for a 4-year-old child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?A)Hemoglobin 6.8 g/dL (9.5 to 14 g/dL)B)WBC count 15,000/mm3 (5,000 to 10,000/mm3)C)RBC count 5/mm3 (4 to 5.5/mm3)D)Platelet count 98,000/mm3 (150,000 to 400,000/mm3)
Exam Review
- A nurse is caring for a 5-year-old child who has acute poststreptococcal glomerulonephritis. Which of the following findings should indicate to the nurse that treatment has been effective?A)Odorless urineB)Temperature 37.2° C (99° F)C)Clear urineD)No report of pain with voiding
- A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?A)Increased dependencyB)Less emotionally labileC)Resistant to routinesD)Frequent negative responses
- A nurse is caring for a 1-week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?A)Monitor the newborn's temperature every 2 hr.B)Place mittens on the newborn's hands.C)Apply lotion to the newborn's skin.D)Check the newborn's eyes every 8 hr.
- A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?A)Heart rate 54/minB)Flushing of the faceC)Continuous swallowingD)Blood pressure 95/56 mm Hg
Exam Review
- A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?A)Set the water heater to 60° C (140° F).B)Keep electrical wires hidden from view.C)Turn pot handles toward the front of the stove.D)Encourage outdoor activities between the hours of 1100 and 1300.
- A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?A)Administer aspirin for fever.B)Provide the child with a warm blanket.C)Initiate airborne precautions.D)Assess the oral cavity for Koplik spots.
- A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?A)The child cries often.B)The child refuses clear liquids.C)The child's throat pain increases.D)The child swallows frequently.
- A nurse is preparing to assess a 4-year-old child's visual acuity. Which of the following actions should the nurse plan to take?A)Use a tumbling E chart for the assessment.B)Assess both eyes together first, then each eye separately.C)Position the child 4.6 meters (15 feet) from the chart.D)Test the child without glasses before testing with glasses.