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NCLEX Pediatrics

Multiple Choice 193 questions Medicine & Health Sciences > Pediatric Nursing by Sean Valentine
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Multiple Choice (193)

Question 1
Order is for gentamicin IV 6 mg/kg/day administered in equally divided doses every 8 hours. Administer each dose over 30 min. Patient weights 64 lbs. Gentamicin 100 mg/50 mL is available. The patient will receive 174.5 mg/day. How many mg will the patient receive per dose?
  • 174.5 mg/dose
  • 58.2 mg/dose ✓
  • 87.3 mg/ose
  • 384 mg/dose
Correct Answer
58.2 mg/dose
First convert 64 lb to 29.09 kg. A patient of this weight should receive 174.5 mg per day. It should be divided into equal doses every 8 hours, which is 3 times per day, which is 58.2 mg per dose.
Question 2
Order reads ampicillin IV 25 mg/kg/day administered in equally divided doses every 6 hours. Patient weighs 73 lbs. Ampicillin 250 mg/1 mL is available. How many mg will the patient receive per day?
  • 1,825 mg/day
  • 456.3 mg/day
  • 829.5 mg/day ✓
  • 207.4 mg/day
Correct Answer
829.5 mg/day
Start by converting 73 lbs to 33.18 kg. Daily the patient should receive 25 mg/kg, and for a patient weighing 33.18 kg that is 829.5 mg daily.
Question 3
A nurse is caring for a patient with ulcerative colitis. Which symptom does the nurse anticipate finding?
  • Diarrhea ✓
  • Abdominal distension
  • Rectal pain
  • Abdominal cramps
Correct Answer
Diarrhea
Ulcerative colitis commonly causes diarrhea and hematochezia. The other findings are more common with Crohn's disease.
Question 4
A nurse is completing an admission for an eighteen year old patient. The patient states "I have been at college for two months and have been having fevers, neck pain, and nausea." What should the nurse do first?
  • Have the patient relax and watch television till the provider comes
  • Implement droplet precautions ✓
  • Draw labs
  • Administer an antipyretic
Correct Answer
Implement droplet precautions
These are signs of meningitis and the patient should be put on droplet precautions for suspected or confirmed cases. A lumbar puncture will be the diagnostic test.
Question 5
A child presents to the emergency department with fruity breath odor, hyperglycemia, deep/rapid respirations, and excessive thirst. What acid/base imbalance does the nurse expect to find in this patient?
  • Metabolic alkalosis
  • Respiratory acidosis
  • Metabolic acidosis ✓
  • Respiratory alkalosis
Correct Answer
Metabolic acidosis
This child is presenting with signs and symptoms of diabetic ketoacidosis. The nurse should expect to find this child in metabolic acidosis.
Question 6
What finding does the nurse expect in a child with a serum digoxin level of 2.6 ng/mL?
  • SpO2 of 85%
  • Decreased DTRs
  • Flight of ideas
  • Bradycardia ✓
Correct Answer
Bradycardia
A serum digoxin level of 2.6 ng/mL is indicative of digoxin toxicity, which is likely to be marked by bradycardia. Decreased DTRs, flight of ideas, and a decreased SpO2 are not findings consistent with digoxin toxicity.
Question 7
A child presents to the emergency room with deep/rapid respirations, fruity breath odor, and lethargy. Which lab value should the nurse assess first?
  • Troponin
  • CBC
  • Urinalysis
  • Capillary blood glucose ✓
Correct Answer
Capillary blood glucose
This child is presenting with signs and symptoms of diabetic ketoacidosis. The nurse should immediately assess the child's capillary blood glucose.
Question 8
The nurse is caring for a pediatric client with an immunosuppressive disorder who has previously undergone cardiac valve replacement. What recommendation will likely be made as a pre-procedural intervention prior to dental surgery?
  • Cardiac stress test
  • CBC and BMP testing
  • Prophylactic antibiotic administration ✓
  • 12-lead EKG
Correct Answer
Prophylactic antibiotic administration
Prophylactic antibiotics should be administered prior to dental or surgical procedures for high-risk patients who have had cardiac valve replacement.
Question 9
The nurse is assessing a 15 year old male patient. Which finding should the nurse report to the provider?
  • Voice has changed since their visit last year
  • States their support system is their friends
  • Plays two different sports at school
  • Food is used as a reward for doing well in school ✓
Correct Answer
Food is used as a reward for doing well in school
Food should not be used as a reward. The other options are expected for a male adolescent.
Question 10
While assessing a 6-month old at a well-child visit, the nurse notes a collection of fluid around the left testicle. How should the nurse describe this finding?
  • Varicocele
  • Hydrocele ✓
  • Epididymitis
  • Testicular torsion
Correct Answer
Hydrocele
Hydrocele is the collection of fluid around a testicle, which is common in infants. This typically resolves without treatment by age 1.
Question 11
The nurse is providing education to a client and their family about taking iron supplements. Which of the following foods should the nurse recommend they to avoid?
  • Lemonade
  • Oranges
  • Cottage cheese ✓
  • Bell peppers
Correct Answer
Cottage cheese
Dairy foods high in calcium, such as cottage cheese, should be avoided when taking iron supplements as they may decrease absorption. Foods high in vitamin C, such as oranges, lemonade, and bell peppers, may actually increase iron absorption and should be consumed.
Question 12
The nurse is reviewing a pediatric client's history in which they exhibt a decrease in pulmonary blood flow. What diagnosis does the nurse anticipate?
  • Patent ductus arteriosus
  • Ventricular septal defect
  • Tetralogy of Fallot ✓
  • Atrial septal defect
Correct Answer
Tetralogy of Fallot
PDA, VSD, and ASD all lead to an increase in pulmonary blood flow. Tetralogy of Fallot results in a decrease in pulmonary blood flow.
Question 13
The nurse is reviewing X-linked disorders with a nursing student. Which disorder if stated by the student as X-linked would require follow up?
  • Epilepsy ✓
  • Color blindness
  • Fragile X syndrome
  • Duchenne's muscular dystrophy
Correct Answer
Epilepsy
Fragile X syndrome, Duchenne's muscular dystrophy, and color blindness are x-linked neurological conditions. Epilepsy is not an x-linked condition.
Question 14
An unconscious child presents to the emergency department with black marks around the nares and singed eyebrow hair. What should the nurse suspect?
  • Smoke inhalation ✓
  • Physical abuse
  • Inhalant drug use
  • Stevens-Johnson syndrome
Correct Answer
Smoke inhalation
A child who has suffered smoke inhalation is likely to have soot around the nares and singed eyebrow hairs.
Question 15
The nurse is preparing to peform an initial assessment on a pediatric client who has sustained burns. How should body surface area be calculated in this situation?
  • Barlow's rule
  • Lund and Browder chart ✓
  • Broselow chart
  • Rule of Nines
Correct Answer
Lund and Browder chart
The Lund and Browder chart should be used to calculate the body surface area affected by burns in a pediatric patient.
Question 16
The nurse is preparing to educate a pediatric client and their family after the child was diagnosed with pediculosis. How should the nurse recommend they care for household items that cannot be washed?
  • Seal them in an airtight bag for two weeks ✓
  • Spray them with bleach
  • They must be thrown away
  • Apply a mixture of hydrogen peroxide and water
Correct Answer
Seal them in an airtight bag for two weeks
Sealing items that cannot be washed in an airtight bag for two weeks will kill off any lice that are on those items.
Question 17
During an assessment, the nurse finds white lines between fingers, toes, and skin folds with severe pruritus. The nurse understands these to be signs of which integumentary disorder?
  • Scabies ✓
  • Pediculosis capitis
  • Pinworms
  • Tinea manuum
Correct Answer
Scabies
Scabies are associated with white "burrow" lines between fingers, toes, and skin folds, with severe itching.
Question 18
The nurse is preparing to provide treatment with selenium sulfide shampoo for a pediatric client. What diagnosis is this child likely experiencing?
  • Tinea pedis
  • Tinea manuum
  • Tinea cruris
  • Tinea capitis ✓
Correct Answer
Tinea capitis
A child with tinea capitis, a fungal infection of the scalp, should be treated with selenium sulfide shampoo.
Question 19
The nurse is providing education to local families on how to prevent/treat diaper dermatits. Which intervention mentioned by a parent would require follow up by the nurse?
  • Change diapers often
  • Use ultra-absorbent diapers
  • Use baby wipes that contain alcohol ✓
  • Apply barrier cream to the perineum
Correct Answer
Use baby wipes that contain alcohol
Changing diapers often, applying barrier cream, and using ultra-absorbent diapers may help to treat or prevent diaper dermatitis. Use of alcohol-containing baby wipes may irritate the infant's skin and should be avoided.
Question 20
The nurse is preparing to educate an adolescent client on their new prescription. Which acne medication is likely prescribed if the nurse is including information on teratogenic effects and the need to have a negative pregnancy test prior to administration?
  • Minocycline
  • Isotretinoin ✓
  • Niacinamide
  • Azelaic acid
Correct Answer
Isotretinoin
Isotretinoin is a highly teratogenic medication used to treat acne. This medication requires a negative pregnancy test prior to administration.
Question 21
A child presents to the clinic with yellow lesions that appear to be "honey-crusted" around the mouth. The nurse knows these are a sign of which integumentary disorder?
  • Tinea capitis
  • Impetigo ✓
  • Parvovirus
  • Pediculosis cruris
Correct Answer
Impetigo
Impetigo is an integumentary disorder marked by yellow "honey-crusted" lesions which typically present around the mouth.
Question 22
The nurse has recieved orders for treatment for both a breastfeeding parent and their child. Which disorder has most likely been found the child?
  • Eczema
  • Oral candidiasis ✓
  • Vulvar candidiasis
  • Seborrheic dermatitis
Correct Answer
Oral candidiasis
Oral candidiasis (i.e., thrush) can be passed from the child's mouth to the parent's breast and back again, so both individuals should be treated.
Question 23
Which integumentary finding should the nurse ensure is documented in a child's chart to avoid future suspicion of physical abuse?
  • Nevus simplex
  • Facial milia
  • Congenital dermal melanocytosis ✓
  • Erythema migrans
Correct Answer
Congenital dermal melanocytosis
Congenital dermal melanocytosis (formerly known by the name "Mongolian spots," which should be avoided) causes flat bluish-gray skin markings commonly appearing at birth or shortly thereafter. These can be confused with bruises and could lead to suspicion of abuse.
Question 24
A pediatric client presents with leukocoria. Which diagnosis does the nurse suspect will be made?
  • Osteosarcoma
  • Wilms' tumor
  • Retinoblastoma ✓
  • Neuroblastoma
Correct Answer
Retinoblastoma
Leukorrhea is associated with retinoblastoma.
Question 25
The nurse is preparing to educate a child and their family about mononucleosis. Which of the following educational points should be included?
  • Contact sports must be avoided ✓
  • Strict bed rest should be followed for 14 days
  • Incentive spirometer should be used several times per hour while awake
  • High dose aspirin should be taken
Correct Answer
Contact sports must be avoided
Due to splenomegaly in mononucleosis, contact sports should be avoided due to the risk for splenic rupture.
Question 26
The nurse suspects a child in the emergency department is suffering from paramyxovirus. Which isolation precautions should be implemented?
  • Contact plus
  • Airborne
  • Contact
  • Droplet ✓
Correct Answer
Droplet
Paramyxovirus (i.e., mumps) requires the use of droplet precautions.
Question 27
A child presents to the emergency department with a maculopapular rash and small white spots on the inside of their cheeks. What condition should the nurse suspect?
  • Paramyxovirus
  • Rubella
  • Parvovirus B19
  • Measles ✓
Correct Answer
Measles
A maculopapular rash and white spots on the oral mucosa (i.e., Koplik spots) are characteristic of measles (i.e., rubeola).
Question 28
The nurse is preparing to educate a pediatric patient and their family about their chickenpox diagnosis. At what point should the nurse indicate the child is no longer contagious?
  • After 14 days
  • 24 hours after resolution of their fever
  • After the rash has disappeared
  • When all lesions have crusted over ✓
Correct Answer
When all lesions have crusted over
Varicella is no longer contagious when the child's lesions have all crusted over.
Question 29
The nurse is preparing to care for a client being admitted for chickenpox. The nurse understands this requires the initiation of which type of transmission precautions?
  • Contact
  • Droplet
  • Airborne ✓
  • Contact plus
Correct Answer
Airborne
Chickenpox (i.e., varicella) requires the use of airborne precautions.
Question 30
A 13-year-old child reports to the nurse that it feels like there is a "bag of worms" in their scrotum. Which disorder should the nurse suspect?
  • Testicular torsion
  • Hydrocele
  • Varicocele ✓
  • Epididymitis
Correct Answer
Varicocele
Varicocele is an enlargement of the veins within the scrotum, which may feel like a "bag of worms" to the patient
Question 31
A child reports unilateral scrotal pain and swelling which has gradually increased in intensity. What condition does the nurse anticipate this child is experiencing?
  • Hydrocele
  • Varicocele
  • Testicular torsion
  • Epididymitis ✓
Correct Answer
Epididymitis
Epididymitis is an infection of the epididymis marked by gradual onset of unilateral scrotal pain and swelling.
Question 32
The nurse is assessing a pediatric patient being admitted to the emergency room. Which of the following findings should lead the nurse to suspect testicular torsion?
  • Abrupt onset of severe unilateral testicular pain ✓
  • The sensation of a "bag of worms" in the scrotum
  • The presence of fluid around one testicle
  • A swollen, red, and warm scrotum
Correct Answer
Abrupt onset of severe unilateral testicular pain
Testicular torsion is a true medical emergency marked by abrupt onset of severe, unilateral testicular pain.
Question 33
The nurse is providing education about cryptorchidism to a family. Which symptom, if mentioned by the family as a complication of cryptorchidism, would require follow up?
  • Disturbed self image
  • Infertility
  • Testicular cancer
  • High fever ✓
Correct Answer
High fever
Cryptorchidism is a condition in which one or both of the testes fail to descend from the abdomen into the scrotum. Complications of this condition include infertility, testicular cancer, and disturbed self image.
Question 34
The nurse is educating a family on their new baby's diagnosis of hypospadias. Which of the following should be included as a teaching point?
  • Treatment of this condition involves a urostomy
  • The child will need to use a straight catheter to urinate for life
  • Antibiotic administration should begin immediately
  • Circumcision should be delayed ✓
Correct Answer
Circumcision should be delayed
Circumcision should be delayed for a child with hypospadias or epispadias as the foreskin may be needed for surgical reconstruction in treatment of these conditions.
Question 35
A child's urinalysis reveals pyuria, leukocyte esterase, and nitrates. What condition should the nurse expect based on these findings?
  • Nephrotic syndrome
  • Urinary tract infection ✓
  • Acute glomerulonephritis
  • Wilms' tumor
Correct Answer
Urinary tract infection
Pyuria (presence of WBC in the urine), leukocyte esterase, and nitrates in the urine are suggestive of a urinary tract infection.
Question 36
The nurse is caring for a child with acute glomerulonephritis. What laboratory finding does the nurse expect?
  • ESR 12 mm/hr
  • BUN 12
  • Positive ASO titer ✓
  • Negative hematuria
Correct Answer
Positive ASO titer
Patients with recent streptococcal infection may develop acute glomerulonephritis. Due to this recent infection, their Antistreptolysin O (ASO) titer would be positive. The other findings are all within normal limits.
Question 37
A child's urinalysis reveals massive proteinuria and their urine is noted to be excessively frothy. What condition should the nurse expect based on these findings?
  • Nephrotic syndrome ✓
  • Acute glomerulonephritis
  • Urinary tract infection
  • Wilms' tumor
Correct Answer
Nephrotic syndrome
Frothy urine with massive proteinuria is consistent with nephrotic syndrome.
Question 38
The nurse is preparing to assess an infant with diarrhea. Which of the following findings would consistent would indicate possible dehydration?
  • Heart rate of 129 bpm
  • 7 wet diapers in a day
  • Bulging fontanelles
  • Absence of tears when crying ✓
Correct Answer
Absence of tears when crying
A heart rate of 129 bpm is within normal limits, and 6 - 8 wet diapers per day is consistent with adequate hydration. Bulging fontanelles is consistent with increased ICP, not dehydration. A child who is crying without producing tears may be dehydrated.
Question 39
The nurse is preparing education for local families about health and safety. What should the nurse should include as the most common cause of diarrhea in children < 5 years old?
  • Enterocolitis
  • Rotavirus ✓
  • C. difficile
  • Enterobiasis
Correct Answer
Rotavirus
The most common cause of diarrhea in children < 5 years old is rotavirus.
Question 40
The nurse is caring for a child who has not passed meconium in the first 48 hours of life, has abdominal distention, and bilious vomiting. The child should be further evaluated for which condition?
  • Hirschsprung disease ✓
  • Enterobiasis
  • Pyloric stenosis
  • Intussusception
Correct Answer
Hirschsprung disease
Failure to pass meconium in the first 48 hours of life, abdominal distention, bilious vomiting, and/or ribbon-like stool are all signs of Hirschsprung disease.
Question 41
The nurse is caring for a patient who is complaining of severe abdominal pain, bloody stools, fever, vomiting, and weight loss. Upon abdominal assessment the nurse notes a sausage shaped-mass in the right upper quadrant. The nurse should expect to prepare the patient for what treatment?
  • Appendectomy
  • Air enema ✓
  • Antibiotics
  • Cholecystectomy
Correct Answer
Air enema
These are signs of intussusception and the nurse should prepare for an air enema to be performed as both a diagnostic test and treatment.
Question 42
The nurse notes a new order for an air enema for a pediatric patient. For what disorder is this intervention a diagnosis and treatment?
  • Intussusception ✓
  • Appendicitis
  • Pyloric stenosis
  • Hirschsprung disease
Correct Answer
Intussusception
Air enema is both the diagnostic test and treatment for intussusception.
Question 43
A child's mother reports that he has been passing stool that looks like grape jelly. The nurse notes a sausage-shaped mass in the RUQ. What condition should the nurse suspect?
  • Hirschsprung disease
  • Hypertrophic pyloric stenosis
  • Omphalocele
  • Intussusception ✓
Correct Answer
Intussusception
Intussusception can present with grape or currant jelly stool and a sausage-shaped mass in the RUQ.
Question 44
An infant presents to the emergency department with an olive-shaped mass in the RUQ and projectile vomiting. What condition does the nurse expect the child has?
  • Omphalocele
  • Intussusception
  • Hypertrophic pyloric stenosis ✓
  • Hirschsprung disease
Correct Answer
Hypertrophic pyloric stenosis
Hypertrophic pyloric stenosis causes projectile vomiting and may cause an olive-shaped mass which can be felt in the RUQ.
Question 45
The nurse is providing education to new parents about their child's diagnosis of gastroesophageal reflux. Which intervention mentioned by a parent would require follow up by the nurse?
  • Treatment with esomeprazole
  • Feed the infant in an upright position
  • Feed the child thickened formula
  • Position the crib in Trendelenburg ✓
Correct Answer
Position the crib in Trendelenburg
Placing a child's crib in Trendelenburg position is not indicated in the treatment of gastroesophageal reflux. Raising the head of the crib may be indicated if ordered by the provider.
Question 46
The nurse is caring for a pediatric client voiding small amounts of concentrated urine and showing signs of fluid volume excess. Which disorder does the nurse anticipate this client is experiencing?
  • Cushing's disease
  • Adrenocortical insufficiency
  • SIADH ✓
  • Diabetes insipidus
Correct Answer
SIADH
Syndrome of inappropriate antidiuretic hormone (SIADH) is an endocrine disorder which results in small amounts of concentrated urine and signs/symptoms of fluid volume excess.
Question 47
The nurse is caring for a pediatric client voiding large amounts of dilute urine and showing signs of fluid volume deficit. Which disorder does the nurse anticipate this client is experiencing?
  • SIADH
  • Adrenocortical insufficiency
  • Diabetes insipidus ✓
  • Cushing's disease
Correct Answer
Diabetes insipidus
Diabetes insipidus is an endocrine disorder marked by large volumes of dilute urine and signs/symptoms of fluid volume deficit.
Question 48
The nurse is providing education to a family about their daughter potentially experiencing precocious puberty. Which of the following findings symptoms if mentioned by a parent would require follow up?
  • Breast development at age 6
  • Amenorrhea until age 13 ✓
  • Menarche at age 7
  • Early occurrence of pubic hair
Correct Answer
Amenorrhea until age 13
Early occurrence of puberty, breast development (e.g., at age 6), and menstruation (e.g., at age 7) are consistent with precocious puberty. Although absence of menstruation until age 13 is an expected finding in an average child, it is an unexpected finding in precocious puberty.
Question 49
The nurse is caring for a child placed in halo traction. Which of the following devices must be present at the bedside at all times?
  • A magnet
  • Lead-lined container
  • A wrench or screwdriver ✓
  • Trauma shears
Correct Answer
A wrench or screwdriver
A wrench or screwdriver must be with a patient in halo traction at all times to release them from the device in case of an emergency.
Question 50
The nurse is caring for a client who requires traction as part of their treatment. How frequently should the nurse allow the weights of traction devices to rest on the floor?
  • For a half hour every 8 hours
  • For 15 minutes of every hour
  • Never ✓
  • For one hour per day
Correct Answer
Never
The weights of traction devices should never rest on the floor. They should hang freely.
Question 51
The nurse is caring for a child in traction with their legs in an extended position. The nurse understands this to be which type of traction?
  • Bryant traction
  • Hamilton-Russell traction
  • Buck's traction ✓
  • Perkins traction
Correct Answer
Buck's traction
Buck's traction is used in the management of femur fractures by keeping the patient's leg in an extended position.
Question 52
The nurse is caring for a child in traction with the legs flexed at 90 degrees and the buttocks raised slightly off the bed. The nurse understands this to be which type of traction?
  • Bryant traction ✓
  • Hamilton-Russell traction
  • Perkins traction
  • Buck's traction
Correct Answer
Bryant traction
Bryant traction involves having the legs of a child flexed at 90 degrees with the buttocks raised slightly off the bed.
Question 53
The nurse is caring for a pediatric client diagnosed with osteomyelitis. How should the nurse describe osteomyelitis to the client and their caregivers?
  • A fracture common in children
  • An infection of the bone ✓
  • Premature closure of the epiphyseal plate
  • Softening of the bones
Correct Answer
An infection of the bone
Osteomyelitis is an infection of the bone.
Question 54
The nurse is caring for a child who has rickets. The nurse educates the parents about this disorder being due to a deficiency of which vitamin?
  • Vitamin K
  • Vitamin D ✓
  • Vitamin A
  • Vitamin C
Correct Answer
Vitamin D
Rickets is bone loss caused by a deficiency of vitamin D.
Question 55
The nurse is caring for a pediatric client with vitamin D deficiency. Which condition does the nurse suspect?
  • Rickets ✓
  • Scurvy
  • Osteogenesis imperfecta
  • Cheilosis
Correct Answer
Rickets
Vitamin D deficiency in childhood can lead to a condition known as Rickets.
Question 56
The nurse is preparing to assess a pediatric client diagnosed with osteogenesis imperfecta. Which finding would require follow up?
  • Fragile bones
  • Blue discoloration of the sclera
  • Hearing loss
  • Yellow-tinged vision ✓
Correct Answer
Yellow-tinged vision
Osteogenesis imperfecta is a genetic condition marked by fragile bones, blue sclera, and hearing loss. Yellow-tinged vision is an unexpected finding in this condition.
Question 57
The nurse is caring for a patient with Legg-Calve-Perthes disease affecting the right leg. What does the nurse expect to find when assessing this child?
  • The right leg is rotated inward
  • The right leg is shorter than the left ✓
  • The right leg is longer than the left
  • The right leg is rotated outward
Correct Answer
The right leg is shorter than the left
In Legg-Calve-Perthes disease the affected leg is shorter.
Question 58
The nurse is caring for a nine month old patient with developmental dysplasia of the hip. Which of the following interventions would be indicated?
  • Hamilton-Russell traction
  • Hip spica cast ✓
  • Pavlik harness
  • Buck's traction
Correct Answer
Hip spica cast
A child with developmental dysplasia of the hip who is > 6 months old will have treatment with a hip spica cast.
Question 59
The nurse is caring for a four month old patient with developmental dysplasia of the hip. Which of the following interventions would be indicated?
  • Hip spica cast
  • Pavlik harness ✓
  • Buck's traction
  • Hamilton-Russell traction
Correct Answer
Pavlik harness
A child with developmental dysplasia of the hip who is < 6 months old will have treatment with a Pavlik harness.
Question 60
The nurse is caring for a child with positive Barlow and Ortolani maneuvers. Which condition does the nurse expect the child has?
  • Osgood-Schlatter disease
  • Legg-Calve-Perthes disease
  • Rickets
  • Developmental dysplasia of the hip ✓
Correct Answer
Developmental dysplasia of the hip
Positive Barlow and Ortolani maneuvers are consistent with developmental dysplasia of the hip.
Question 61
When assessing a child for scoliosis during a well-child visit, what test should the nurse perform?
  • Ishihara test
  • Adams test ✓
  • Ortolani maneuver
  • McMurray test
Correct Answer
Adams test
The Adams test (or "Adams forward bend test") is used to assess for scoliosis.
Question 62
When assessing a child during a well-child visit, the nurse notes asymmetry of the ribs and flanks. The child should receive further evaluation for which condition?
  • Costochondritis
  • Scoliosis ✓
  • Thoracic kyphosis
  • Lumbar lordosis
Correct Answer
Scoliosis
Children with scoliosis may have asymmetry of the ribs, flanks, and gluteal folds.
Question 63
A nurse is providing teaching to the parents of an infant with positional plagiocephaly. The nurse tells them the helmet should be worn up to how many hours per day?
  • 6 hours
  • 12 hours
  • 24 hours
  • 23 hours ✓
Correct Answer
23 hours
A child undergoing helmet therapy for positional plagiocephaly should wear it up to 23 hours/day.
Question 64
The nurse is caring for a patient and assesses low set ears, single uninterrupted palmar crease, broad flat nose, and a protruding tongue. Which disorder is indicated by these physical features?
  • Fragile X Syndrome
  • ADHD
  • Duchenne's muscular dystrophy
  • Trisomy 21 (Down syndrome) ✓
Correct Answer
Trisomy 21 (Down syndrome)
These are all signs of Trisomy 21 (Down syndrome). Other signs include congenital heart defects, GI disorders, intellectual and developmental disabilities.
Question 65
The nurse is preparing to care for an infant with spina bifida. In which positions would it be appropriate for the nurse to place this patient?
  • Prone with their hips flexed ✓
  • Supine with legs flexed inward
  • Trendelenburg
  • Reverse trendelenburg
Correct Answer
Prone with their hips flexed
An infant with spina bifida should be placed prone with their hips flexed.
Question 66
A nurse is caring for an infant with spina bifida. The nurse understands this disorder can be caused by the lack of which nutrient during pregnancy?
  • Folic acid ✓
  • Vitamin C
  • Calcium
  • Iron
Correct Answer
Folic acid
Spina bifida can be caused by insufficient folic acid intake during pregnancy, maternal diabetes, or maternal drug use.
Question 67
The nurse asks a child's parent when their house was built to assess for lead poisoning risk. Which of the following answers puts the child at increased risk for lead poisoning?
  • 1979
  • 1974 ✓
  • 1983
  • 1989
Correct Answer
1974
Houses built prior to 1978 are at high risk for causing lead poisoning.
Question 68
A nurse is caring for a patient with vomiting, confusion, and seizure. The child is diagnosed with Reye's syndrome. The nurse understands this was likely caused by the use of which medication?
  • Acetaminophen
  • Aspirin ✓
  • Penicillin
  • Cephalosporin
Correct Answer
Aspirin
Reye's syndrome is caused by the use of salicylates (aspirin) in children.
Question 69
The nurse is reviewing the ceberospinal fluid findings for a pediatric patient diagnosed with viral meningitis. Which of the following findings would require the nurse to follow up?
  • Normal protein
  • Decreased glucose ✓
  • Clear fluid
  • Negative gram staining
Correct Answer
Decreased glucose
Clear CSF with normal glucose, normal protein, and negative gram staining is consistent with viral meningitis. Decreased glucose is consistent with bacterial meningitis.
Question 70
Laboratory analysis of a child's cerebrospinal fluid shows that it is cloudy with decreased glucose, increased protein, and a positive gram stain. What condition should the nurse suspect as consistent with these findings?
  • Guillain-Barre syndrome
  • Viral meningitis
  • Bacterial meningitis ✓
  • Multiple sclerosis
Correct Answer
Bacterial meningitis
Cloudy CSF with decreased glucose, increased protein, and positive gram staining is consistent with bacterial meningitis.
Question 71
A nurse is educating a pediatric client's family about the child's nervous disorder and states that it is characterized by increased cerebrospinal fluid volume due to impaired reabsorption or an outflow issue. Which diagnosis is this nurse explaining?
  • Hydrocephalus ✓
  • Meningitis
  • Spina bifida
  • Anencephaly
Correct Answer
Hydrocephalus
Hydrocephalus is a condition characterized by increased CSF due to impaired reabsorption or an outflow issue.
Question 72
A child presents to the emergency room with an accumulation of blood within the brain tissue. What type of condition is this patient experiencing?
  • Epidural hematoma
  • Intracerebral hemorrhage ✓
  • Subdural hematoma
  • Subarachnoid hemorrhage
Correct Answer
Intracerebral hemorrhage
An intracerebral hemorrhage is a bleed occuring within the brain tissue.
Question 73
After being hit in the head with a basketball during gym, the school nurse should provide which intervention prior to transport to the hospital?
  • Complete neurological testing
  • Assess the child's range of motion in their neck and shoulders
  • Place the child in halo traction
  • Stabilization of the cervical spine ✓
Correct Answer
Stabilization of the cervical spine
Following a head injury, the child should have stabilization of the cervical spine with a c-collar prior to transport to the hospital.
Question 74
A caregiver reports to the nurse that their child often appears to be staring off into space, daydreaming. What type of seizure does the nurse expect the child may be experiencing?
  • Myoclonic seizure
  • Absence seizure ✓
  • Tonic clonic seizure
  • Atonic seizure
Correct Answer
Absence seizure
An absence seizure may be marked by periods of what appears to be daydreaming.
Question 75
The nurse is assessing a newborn who is deaf. Which reflex does the nurse anticipate the child will lack?
  • Tonic neck reflex
  • Stepping reflex
  • Rooting reflex
  • Startle reflex ✓
Correct Answer
Startle reflex
A child with an inability to hear would not be able to exhibit the startle reflex, as this reflex is present in response to a loud noise.
Question 76
The nurse is preparing to assess a child's ability to see color. Which vision screening tool should the nurse use?
  • Slit-lamp exam
  • Snellen test
  • Ishihara test ✓
  • Tonometry
Correct Answer
Ishihara test
The Ishihara test is used to test for color vision.
Question 77
The nurse is preparing to assess a client for strabismus. Which of the following vision screening tools should be used?
  • Six cardinal positions
  • Corneal light reflex ✓
  • Confrontation
  • Pupillary light reflex
Correct Answer
Corneal light reflex
The corneal light reflex and cover test are two vision screening tools which can be used to assess for strabismus.
Question 78
The nurse is preparing to assess a pediatric client's visual acuity. How far away from the Snellen chart should the nurse position the child?
  • 20 feet
  • 5 feet
  • 15 feet
  • 10 feet ✓
Correct Answer
10 feet
A pediatric patient should be 10 feet away from the Snellen chart, while an adult should be 20 feet away.
Question 79
The nurse is preparing to provide education to a pediatric client's parents after a new diagnosis. How should the nurse describe strabismus?
  • Decreased ability to hear high-pitched sounds
  • Decreased visual acuity of one eye
  • Dizziness related to inner-ear dysfunction
  • Misalignment of the eyes ✓
Correct Answer
Misalignment of the eyes
Strabismus is a term used to describe misalignment of the eyes (i.e., inward or outward deviation).
Question 80
The nurse is preparing to provide education to a pediatric client's parents after a new diagnosis. How should the nurse describe amblyopia?
  • Bilateral blindness
  • Outward deviation of both eyes
  • Decreased visual acuity of one eye ✓
  • Inward deviation of both eyes
Correct Answer
Decreased visual acuity of one eye
Amblyopia is a term describing decreased visual acuity in one eye (i.e., a "lazy eye")
Question 81
The nurse is caring for an infant experiencing increased intracranial pressure. Which of the following findings would the nurse anticipate assessing?
  • Depressed fontanelles
  • Weak cry
  • Appropriate feeding
  • Increased irritability ✓
Correct Answer
Increased irritability
Irritability, bulging fontanelles, and poor feeding are all findings consistent with increased ICP in an infant. The infant would demonstrate a high-pitched cry, not a weak cry.
Question 82
The nurse is preparing to assist with a lumbar puncture. Which medication could the nurse anticipate administering to the site prior to the procedure to decrease pain?
  • EMLA cream ✓
  • Hydrocortisone cream
  • Erythromycin ointment
  • Topical morphine
Correct Answer
EMLA cream
EMLA cream is a topical analgesic which may be applied to the skin prior to a lumbar puncture to decrease pain.
Question 83
The nurse is preparing to give a patient a prescribed iron supplement. Which fluid would be best to offer this patient?
  • Water
  • Orange juice ✓
  • Milk
  • Tea
Correct Answer
Orange juice
Vitamin C increases absorption of iron.
Question 84
The nurse is reviewing Kawasaki disease with a student nurse. Which finding, if stated by the student as consistent with the disease, would require follow up?
  • Swollen, tender lymph nodes
  • 3+ patellar DTR ✓
  • Erythema of the tongue
  • Temperature of 103.2° F
Correct Answer
3+ patellar DTR
Kawasaki disease causes red eyes, lips, tongue, palms, soles, high fever, arthritis, lymphadenopathy, and cardiac abnormalities. Kawasaki disease does not cause increased DTRs.
Question 85
The nurse is caring for a pediatric client who has been admitted for left-sided heart failure. Which finding does the nurse anticipate assessing?
  • Ascites
  • Jugular vein distention
  • Intercostal retractions ✓
  • Peripheral edema
Correct Answer
Intercostal retractions
Intercostal retractions are suggestive of left-sided heart failure. Ascites, JVD, and peripheral edema are findings consistent with right-sided heart failure.
Question 86
The nurse is reviewing the three surgical procedures for a child's hypoplastic left heart syndrome with student nurses. Which of the following procedure mentioned by a student nurse would require follow up?
  • Fontan procedure
  • Glenn shunt
  • Transmyocardial revascularization ✓
  • Norwood procedure
Correct Answer
Transmyocardial revascularization
The three stages of surgery to treat hypoplastic left heart syndrome are the Norwood procedure, Glenn shunt, and Fontan procedure.
Question 87
The nurse is explaining to a parent the congenital heart defect of their child. The nurse states, "The connections of their aorta and pulmonary artery are reversed." Which condition is the nurse describing?
  • Atrial septal defect
  • Tetralogy of Fallot
  • Transposition of the great arteries ✓
  • Truncus arteriosus
Correct Answer
Transposition of the great arteries
Transposition of the great arteries occurs when the aorta and pulmonary artery connections to the heart are reversed.
Question 88
The nurse auscultates a loud holosystolic murmur at the left sternal border when assessing a pediatric client. Which congenital heart defect does the nurse expect the child has?
  • Atrial septal defect
  • Ventricular septal defect ✓
  • Truncus arteriosus
  • Patent ductus arteriosus
Correct Answer
Ventricular septal defect
Ventricular septal defect is marked by a loud holosystolic murmur which can be auscultated at the left sternal border.
Question 89
The nurse is reviewing a pediatric client's history in which they exhibt an increase in pulmonary blood flow. What diagnosis does the nurse anticipate?
  • Atrioventricular canal defect ✓
  • Pulmonary atresia
  • Transposition of the great arteries
  • Tricuspid atresia
Correct Answer
Atrioventricular canal defect
Tricuspid atresia, pulmonary atresia, and TGA all lead to decreased pulmonary blood flow. AV Canal defect increases pulmonary blood flow.
Question 90
The nurse is providing safe sleep education for new families. Which intervention mentioned by a parent as a step to reduce the risk for SIDS would require follow up by the nurse?
  • Place the child supine for sleep
  • Keep the child's crib close to a heat vent ✓
  • Obtain childhood vaccinations
  • Breastfeed the infant
Correct Answer
Keep the child's crib close to a heat vent
SIDS risk may be decreased by breastfeeding, avoiding passive smoke exposure, obtaining proper prenatal and pediatric care, obtaining childhood vaccines, using a firm mattress, and placing the infant alone, on their back, in a crib with a firm mattress. The child's crib should be kept away from heat vents to decrease the risk for overheating.
Question 91
The nurse is preparing to care for a neonatal patient with resipratory distress syndrome. Which treatment does the nurse anticipate providing?
  • Frequent oropharyngeal suctioning
  • Surfactant ✓
  • Albuterol
  • Oseltamivir
Correct Answer
Surfactant
Neonates with respiratory distress syndrome should be given surfactant to prevent alveolar collapse.
Question 92
A caregiver reports that when they kiss their child, their skin tastes salty. Which diagnostic testing does the nurse expect for further investigation?
  • Heel stick capillary blood glucose
  • Pulmonary function tests
  • Sweat chloride test ✓
  • BMP for electrolyte abnormalities
Correct Answer
Sweat chloride test
Infants with salty skin may have cystic fibrosis. Further evaluation with a sweat chloride test may be indicated.
Question 93
A nurse is providing teaching to an adolescent recently diagnosed with asthma. The nurse is teaching how to use a peak flow meter. Which of the following is a correct teaching point?
  • Use the highest of three readings ✓
  • Use the average of three readings
  • Record the first and last reading
  • Record the lowest of three readings
Correct Answer
Use the highest of three readings
The proper number to record is the highest of three readings.
Question 94
A nurse is caring for a 10 year old patient who has been diagnosed with influenza type A. The patient's parent requests an antiviral. Which statement regarding antivirals for influenza is correct?
  • Antiviral administration must begin within two days of symptom onset ✓
  • A culture must be done prior to initiation
  • The child can only take aspirin for fever
  • Fluids should be limited
Correct Answer
Antiviral administration must begin within two days of symptom onset
Antivirals for influenza (e.g., oseltamivir) must be started within two days of symptom onset. Children should avoid aspirin due to the risk of Reye's syndrome. Fluids should be increased when sick with influenza. A culture is required for antibiotics, not antivirals.
Question 95
The nurse is providing education about vaccinations to a new family. The nurse should include that the child is eligible to begin receiving seasonal influenza vaccinations at what age?
  • 3 months
  • 1 month
  • 6 months ✓
  • 1 year
Correct Answer
6 months
Seasonal influenza vaccinations may be administered to children beginning at 6 months of age.
Question 96
The nurse is caring for a pediatric client diagnosed with pertussis. Which isolation precautions should the nurse implement?
  • Airborne precautions
  • Droplet precautions ✓
  • No precautions needed
  • Contact plus precautions
Correct Answer
Droplet precautions
The nurse should implement droplet precautions for a child with pertussis.
Question 97
A parent states to the nurse that their daughter has been coughing frequently with a high pitched "whoop" sound upon inhalation. The nurse expects a diagnosis of which condition?
  • Bronchiolitis
  • Pertussis ✓
  • RSV
  • Influenza
Correct Answer
Pertussis
Pertussis is colloquially known as whooping cough due to the characteristic high pitched whooping sound upon inhalation.
Question 98
While assessing a child who presents with respiratory symptoms, the nurse notes that the child has a barking cough. What condition does the nurse anticipate the child may have?
  • Influenza
  • Pertussis
  • RSV
  • Acute laryngotracheobronchitis ✓
Correct Answer
Acute laryngotracheobronchitis
Patients with acute laryngotracheobronchitis (i.e., croup) have a characteristic "barking" cough.
Question 99
A few days following a tonsillectomy, a child is ready to try eating food. Which of the following would be an appropriate food for the child to try?
  • Tomato soup
  • Grilled cheese sandwich
  • Cottage cheese ✓
  • Toast with orange marmalade
Correct Answer
Cottage cheese
For at least a week following tonsillectomy, patients should avoid hot, spicy, sharp, citrus, and red foods. Of the listed options, cottage cheese is the only appropriate choice.
Question 100
The nurse educates a parent the need for complete treatment of strep throat to avoid complications. The nurse asks the parent to teach back the potential complications. Which of the following would require follow up?
  • Kawasaki disease ✓
  • Scarlet fever
  • Rheumatic fever
  • Acute glomerulonephritis
Correct Answer
Kawasaki disease
Scarlet fever, rheumatic fever, and acute glomerulonephritis are potential complications of strep throat. Kawasaki disease is not a result of strep throat.
Question 101
A child presents with redness and itching of the ear canal following a vacation to the beach. Which condition does the nurse anticipate the child is experiencing?
  • Ménière disease
  • Otitis interna
  • Otitis media
  • Otitis externa ✓
Correct Answer
Otitis externa
Otitis externa, commonly known as "swimmer's ear" is an infection of the outer ear canal which can present following water-based activities, such as swimming.
Question 102
The nurse receives report that a child with a cancer is struggling with body image issues related to how their treatment has caused them to lose their hair and develop a round face. What age range does the nurse anticipate for this child?
  • Preschooler
  • Toddler
  • School age
  • Adolescence ✓
Correct Answer
Adolescence
Adolescent children often experience body image issues related to the concept of illness and death.
Question 103
The nurse is providing education to caregivers about dental health. The nurse should teach the caregivers that their child's first permanent teeth should erupt around what age?
  • 6 years ✓
  • 2 years
  • 8 years
  • 4 years
Correct Answer
6 years
Permanent teeth begin to erupt around 6 years old.
Question 104
The nurse is preparing to provide a parenting class to local families. For what age group should the nurse say associative and dramatic play are appropriate?
  • Preschoolers ✓
  • Infants
  • Toddlers
  • School-age children
Correct Answer
Preschoolers
Associative and dramatic play are likely to be seen in preschoolers (3 - 6 years old).
Question 105
The nurse is preparing to provide a parenting class to local families. At what age does the nurse say a child should be able to use scissors?
  • 6 years old
  • 4 years old ✓
  • 2 years old
  • 18 months old
Correct Answer
4 years old
By age 4, a child should be able to use scissors.
Question 106
When assessing children at a well-child clinic, the nurse should expect parallel play to be demonstrated by a child of which of the following ages?
  • 4 years old
  • 6 years old
  • 2 years old ✓
  • 6 months old
Correct Answer
2 years old
Parallel play (i.e., playing independently next to other children) is a behavior expected of toddlers (1 - 3 years old).
Question 107
The nurse is assessing a three year old patient's fine motor skills. Which of the following tasks should this child be able to perform?
  • Draw a circle ✓
  • Use scissors
  • Tie shoes
  • Draw a square
Correct Answer
Draw a circle
A 3-year-old child should be able to draw a circle.
Question 108
The nurse educates caregivers that their child should see a dentist within 6 months of their first tooth erupting, or at which other milestone?
  • 1 year of age ✓
  • When they begin walking
  • When they can eat solid foods
  • When they say their first word
Correct Answer
1 year of age
Children should have their first dental appointment at 1 year of age or within 6 months of the first tooth erupting, whichever comes first.
Question 109
The nurse is hosting an education event for new parents. At what age should the nurse recommend the families introduce whole milk?
  • 9 months
  • 6 months
  • 12 months ✓
  • 18 months
Correct Answer
12 months
At one year of age, whole milk should be introduced to a child.
Question 110
The nurse is preparing an education event for new parents. Which type of play should the nurse include as likely for a one-year-old child?
  • Solitary ✓
  • Associative
  • Parallel
  • Cooperative
Correct Answer
Solitary
Infants are likely to play by themselves, which is known as "solitary play." Parallel play is the next stage of play this child will likely engage in.
Question 111
During a well-child exam, a parent hands their 7-month-old child to the nurse and the child begins crying. The nurse understands this to be considered what behavior?
  • White coat syndrome
  • Despondency
  • Stranger anxiety ✓
  • Separation anxiety
Correct Answer
Stranger anxiety
A child who becomes distressed when held by an unfamiliar person is demonstrating the normal behavior known as stranger anxiety.
Question 112
A parent reports to the nurse that their infant becomes distressed whenever they are not present. The nurse educates the parent that this is known as what?
  • Despair
  • Stranger anxiety
  • Despondency
  • Separation anxiety ✓
Correct Answer
Separation anxiety
Separation anxiety is a normal behavior wherein a child becomes distressed when their parent is not present.
Question 113
The nurse is caring for an infant. When assessing their mouth, at what age does the nurse expect the infant to have at least one tooth?
  • 6 months ✓
  • 12 months
  • 10 months
  • 2 months
Correct Answer
6 months
Tooth eruption typically begins around 6 months of age.
Question 114
The nurse is preparing to assess an infant. Within what age range does the nurse anticipate the anterior fontanelle closing?
  • 18 - 24 months
  • 6 - 12 months
  • 12 - 18 months ✓
  • 2 - 6 months
Correct Answer
12 - 18 months
The anterior fontanelle should close between 12 - 18 months of age
Question 115
The nurse is preparing to assess an intant. At what age does the nurse expect the infant's birth weight to have doubled?
  • 6 months ✓
  • 18 months
  • 12 months
  • 2 months
Correct Answer
6 months
An infant should double their birth weight by 6 months.
Question 116
The nurse assesses an infant and finds their head and chest circumference are approximately equal. At approximately what age does this occur?
  • 18 months
  • 4 months
  • 12 months ✓
  • 6 months
Correct Answer
12 months
A child's head and chest circumference should be approximately equal at 12 months of age.
Question 117
The nurse is caring for a four-year-old child whose parent recently died. Which behavior does the nurse anticipate for this child?
  • Immediate acceptance of the loss of their parent
  • An understanding that their parent's death is permanent and they will not return
  • Disruption in their sense of self within the family unit
  • Frequent accidents although the child is toilet trained ✓
Correct Answer
Frequent accidents although the child is toilet trained
Preschoolers may experience regression in response to the death of a loved one. It is not until school age that a child is likely to understand the permanence of death.
Question 118
The nurse is prerparing to administer a vaccine to a two year old patient. The parent states they plan on administering pain medication for pain relief. Which medication stated by the parent would require follow up by the nurse?
  • Ice packs
  • Ibuprofen
  • Acetaminophen
  • Aspirin ✓
Correct Answer
Aspirin
Due to the risk for Reye's syndrome, aspirin should be avoided.
Question 119
The nurse is preparing to administer an intramuscular (IM) injection to a 6 month old patient. Which musle would be most appropriate for the nurse to use?
  • Deltoid
  • Ventrogluteal
  • Vastus medialis
  • Vastus lateralis ✓
Correct Answer
Vastus lateralis
A child < 1 year of age should receive IM injections in the vastus lateralis muscle.
Question 120
The nurse is preparing to administer a hepatitis B vaccine. For which allergy should the nurse assess?
  • Egg
  • Yeast ✓
  • Peanuts
  • Shellfish
Correct Answer
Yeast
Children with a true allergy to yeast should not receive the hepatitis B vaccine.
Question 121
A nurse is providing care to an eighteen year old patient. The patient is preparing to live on campus at college. Which vaccination will most likely be given at this visit?
  • Varicella vaccine
  • Pneumococcal vaccine
  • Influenza vaccine
  • Meningococcal vaccine ✓
Correct Answer
Meningococcal vaccine
The meningococcal vaccine is given to prevent the spread of meningitis in communal living quarters, such as dorms at college.
Question 122
The nurse is reviewing the recommended vaccine schedule with a family present for their 12-month old's well-child exam. Which vaccine mentioned by the family would require follow up?
  • PCV
  • Rotavirus ✓
  • Hib
  • MMR
Correct Answer
Rotavirus
Rotavirus vaccination is administered at two, four, and six months.
Question 123
The nurse is providing education about vaccinations to a new family. How many doses of the MMR vaccine should be recommended for children?
  • 1
  • 2 ✓
  • 3
  • None
Correct Answer
2
The first at age 12 - 15 months, and the second dose between 4 - 6 years old.
Question 124
The nurse is assessing a new pediatric admission. Which of the following weight percentiles would require further evaluation?
  • 20th %ile
  • 4th %ile ✓
  • 82nd %ile
  • 95th %ile
Correct Answer
4th %ile
Growth chart percentiles < 5th %ile and > 95th %ile require further evaluation.
Question 125
The nurse is caring for a pediatic client who has sustained a fracture. The nurse may suspect physical abuse if it is classified as which type of fracture?
  • Spiral ✓
  • Greenstick
  • Open
  • Comminuted
Correct Answer
Spiral
A spiral fracture may indicate a twist injury and can be consistent with physical abuse.
Question 126
The nurse is caring for a child and suspects that the child may be being physically abused. What action should the nurse take?
  • Interview the parents and document the conversation in the child's medical record
  • Inform the physician so they may perform a forensic examination
  • Report it to the proper authorities ✓
  • Report the concern to their charge nurse
Correct Answer
Report it to the proper authorities
A nurse is a mandated reporter, meaning that they must report any suspicion of child abuse. The nurse does not have the burden of proof, and should report their suspicions to the proper authorities.
Question 127
The nurse is providing education to local families on choking hazards and safe foods for young children. Which of the following would be considered a safe food?
  • Grapes
  • Cubes of cheese
  • Popcorn
  • Rolled up lunch meat ✓
Correct Answer
Rolled up lunch meat
Examples of choking hazards for young children include hot dogs, nuts, seeds, whole grapes, popcorn, gum, hard or sticky candy, chunks of meat, chunks of cheese, peanut butter, and raw vegetables. Rolled up lunch meat is unlikely to be a choking hazard.
Question 128
The nurse is providing health and safety education to local families. During the discussion, which intervention for a choking child stated by a parent would require follow up?
  • Blind finger sweeps ✓
  • Chest thrusts
  • Back blows
  • Heimlich maneuver
Correct Answer
Blind finger sweeps
Blind finger sweeps can lodge an item further into a child's airway. Depending on the age of the child, chest thrusts, back blows, and the heimlich maneuver may be indicated.
Question 129
The nurse is caring for a child with iron overload. Which of the following treatments does the nurse anticipate being ordered by the provider?
  • Chelation therapy ✓
  • Brachytherapy
  • Induced vomiting
  • Administration of acetylcysteine
Correct Answer
Chelation therapy
Chelation therapy is used to treat children with iron overload.
Question 130
The nurse is preparing to administer acetylcysteine. The nurse anticipates this being used for which medication overdose?
  • Oxycodone
  • Heparin
  • Acetaminophen ✓
  • Lorazepam
Correct Answer
Acetaminophen
Acetylcysteine is used in the management of acetaminophen toxicity.
Question 131
The nurse is educating new parents on health and safety. Included in the topics, the nurse should recommend they ensure their home's water heater is set at or below what temperature?
  • 140 degrees F
  • 130 degrees F
  • 120 degrees F ✓
  • 100 degrees F
Correct Answer
120 degrees F
To prevent burns, the home's water heater should be set at or below 120 degrees F.
Question 132
A nurse is providing patient teaching to a new parent. The nurse is explaining the best location for the infant car seat. Which is the safest option?
  • In the back seat, middle seat, rear-facing ✓
  • In the back seat, drivers side, rear-facing
  • In the back seat, middle seat, front-facing
  • In the back seat, drivers side, front-facing
Correct Answer
In the back seat, middle seat, rear-facing
The safest place for an infant car seat is the back seat, middle seat, with a rear-facing car seat.
Question 133
A child states that they live at home with their two sisters and their parents. The nurse correctly identifies this as which type of family?
  • Binuclear
  • Extended
  • Nuclear ✓
  • Blended
Correct Answer
Nuclear
A nuclear family consists of parents and their children.
Question 134
A child states that they live at home with their parents and two of their grandparents. The nurse correctly identifies this as which type of family?
  • Extended ✓
  • Binuclear
  • Blended
  • Nuclear
Correct Answer
Extended
An extended family is one that extends past a traditional nuclear family, including grandparents or other relatives living in the same household.
Question 135
A pediatric patient has been diagnosed with appendicitis. Where does the nurse anticipate the patient reporting pain?
  • McMurray's point
  • Murphy's point
  • McBurney's point ✓
  • Meniere's point
Correct Answer
McBurney's point
McBurney's point (located within the RLQ) is the point at which most patients experience pain associated with appendicitis.
Question 136
The nurse is caring for a pediatric client receiving growth hormone replacement therapy. At what point should this treatment cease?
  • At age 13
  • When the child reaches an average height
  • Once epiphyseal fusion has occurred ✓
  • If the child experiences any fractures
Correct Answer
Once epiphyseal fusion has occurred
Growth hormone replacement should be discontinued upon epiphyseal fusion.
Question 137
A child in diabetic ketoacidosis is being treated in the emergency department. What type of respirations does the nurse expect to observe in this patient?
  • Cheyne-Stokes respirations
  • Kussmaul respirations ✓
  • Biot's respirations
  • Eupnea
Correct Answer
Kussmaul respirations
A child in DKA will likely exhibit Kussmaul respirations to compensate for the metabolic acidosis they are experiencing.
Question 138
Which of the following serum digoxin levels should the nurse interpret as being therapeutic?
  • 0.4 ng/mL
  • 2.1 ng/mL
  • 3.1 ng/mL
  • 1.7 ng/mL ✓
Correct Answer
1.7 ng/mL
The therapeutic serum digoxin level is 0.5 - 2.0 ng/mL. Therefore, the finding of 1.7 ng/mL is the only within therapeutic range.
Question 139
The nurse is planning out their patient assignment's medication administration for a shift. When considering routes, which of the following injections requires use of the Z-track method?
  • IPV
  • Influenza vaccine
  • Iron ✓
  • Vitamin K
Correct Answer
Iron
IM iron should be administered using the Z-track method.
Question 140
Which cardiac anomaly is the nurse describing when they state that the blood vessel coming out of the heart failed to separate completely during development?
  • Patent ductus arteriosus
  • Tetralogy of Fallot
  • Truncus arteriosus ✓
  • Atrial septal defect
Correct Answer
Truncus arteriosus
Truncus arteriosus is a condition marked by a single vessel exiting the heart instead of two.
Question 141
The nurse is caring for a pediatric client with a history of ductus arteriosus. Which type of murmur does the nurse anticipate assessing when auscultating heart sounds?
  • Continuous machine-hum murmur ✓
  • Wide split murmur during S2
  • Holosystolic murmur
  • Diastolic murmur
Correct Answer
Continuous machine-hum murmur
A machine-hum murmur throughout systole and diastole is expected in a child with a PDA.
Question 142
The nurse is caring for a pediatric client with a history of patent ductus arteriosus. Which medication does the nurse anticipate adminstering?
  • Indomethacin ✓
  • Etanercept
  • Imipenem
  • Pegfilgrastim
Correct Answer
Indomethacin
Indomethacin, an NSAID, is used to treat patent ductus arteriosus.
Question 143
The nurse is admitting an eight year old patient experiencing strawberry red tongue, red palms, and a high fever. The nurse understands these are likely signs of which disease?
  • Kawasaki disease ✓
  • Sickle cell anemia
  • Rheumatic fever
  • Cystic fibrosis
Correct Answer
Kawasaki disease
Kawasaki disease causes red eyes, lips, tongue, palms, soles, high fever, arthritis, lymphadenopathy, and cardiac abnormalities.
Question 144
The nurse is providing education regarding the differences between Hemophilia A and B. The nurse should include that hemophilia B is a deficiency of which factor?
  • Factor VI
  • Factor VIII
  • Factor IX ✓
  • Factor V
Correct Answer
Factor IX
Hemophilia B is caused by a deficiency of factor IX.
Question 145
A nurse is caring for a pediatric client who has a patent ductus arteriosus (PDA).The nurse knows this defect occurs between which vessels of the heart?
  • Pulmonary artery and aorta ✓
  • Pulmonary artery and pulmonary veins
  • Aorta and pulmonary veins
  • Aorta and superior vena cava
Correct Answer
Pulmonary artery and aorta
PDA is an opening between the two major blood vessels from the heart, the pulmonary artery and the aorta.
Question 146
A pediatric client with a congenital heart defect is experiencing a cyanotic episode. How should the nurse position this patient?
  • Supine
  • Knee-chest position ✓
  • Reverse trendelenburg
  • High Fowler's
Correct Answer
Knee-chest position
Knee-chest position is indicated for a child experiencing a cyanotic episode.
Question 147
The nurse is caring for a pediatric client experiencing a Wilms' tumor. When preparing for the assessment, which part of the body should the nurse avoid palpating?
  • Abdomen ✓
  • Lower extremities
  • Upper extremities
  • Head and neck
Correct Answer
Abdomen
The nurse should avoid abdominal palpation in a child with Wilms' tumor as this can lead to a rupture of the encapsulated tumor.
Question 148
The nurse is caring for a child with testicular torsion. The nurse should educate his family that which of the following treatments will be a priority?
  • Immediate surgical repair ✓
  • Treatment with IV antibiotics
  • Placement of an indwelling urinary catheter
  • Use of a testicular sling
Correct Answer
Immediate surgical repair
Testicular torsion is a true medical emergency marked by abrupt onset of severe, unilateral testicular pain which requires immediate surgical repair.
Question 149
The nurse is providing a parenting class for expecting parents. When preparing a session on car seat safety, how should the nurse describe the positioning of the chest clip?
  • At the level of the child's umbilicus
  • At the level of the child's xiphoid process
  • At the level of the child's collarbones
  • At the level of the child's nipples ✓
Correct Answer
At the level of the child's nipples
Proper chest clip positioning for a car seat should be at the level of the child's nipples or armpits.
Question 150
The nurse recommends a parent perform a tape test on their child. What disorder does the nurse expect the child has?
  • Cystic fibrosis
  • Enterobiasis ✓
  • Pyloric stenosis
  • Intussusception
Correct Answer
Enterobiasis
Testing for enterobiasis (i.e., pinworms) can be performed by place a piece of tape on the child's perianal skin first thing in the morning when the child awakens.
Question 151
The nurse is admitting a patient with a diagnosis of measles. What is the appropriate transmission precaution for the nurse to initiate?
  • Contact
  • Droplet
  • No precautions needed
  • Airborne ✓
Correct Answer
Airborne
Airborne precautions are necessary for measles and should be continued for four days after the onset of the rash.
Question 152
The nurse is admitting a patient who is drooling, has a hoarse voice, dysphagia, and appears to be in respiratory distress. What is the priority action for this nurse?
  • Put the patient in a supine position
  • Prepare for intubation ✓
  • Administer an antibiotic
  • Take a throat culture
Correct Answer
Prepare for intubation
This patient likely has epiglottitis and the priority is to secure the airway with intubation. The nurse should not put anything in the patient's mouth and should not allow them to lay flat.
Question 153
A parent reports to the nurse that their child is experiencing severe anal itching which is worse at night. What condition does the nurse expect the child has?
  • Mites
  • Pediculosis capitis
  • Scabies
  • Enterobiasis ✓
Correct Answer
Enterobiasis
Enterobiasis (i.e., pinworms) can cause intense anal itching which becomes worse at night.
Question 154
When caring for neonates, which pain scale should the nurse utilize?
  • Numeric scale
  • CRIES scale ✓
  • OUCHER
  • Wong-Baker
Correct Answer
CRIES scale
The CRIES scale should be used to assess pain in a neonatal patient.
Question 155
The nurse auscultates a systolic murmur with wide, fixed splitting of S2 on a pediatric client. Which congenital heart defect does the nurse expect the child has?
  • Truncus arteriosus
  • Ventricular septal defect
  • Atrial septal defect ✓
  • Patent ductus arteriosus
Correct Answer
Atrial septal defect
Atrial septal defect is characterized by a systolic murmur with wide, fixed splitting of S2.
Question 156
The nurse is caring for a child undergoing hemoglobin electrophoresis. The nurse knows this test is diagnostic for which condition?
  • HIV
  • Cystic fibrosis
  • Deep vein thrombosis
  • Sickle cell anemia ✓
Correct Answer
Sickle cell anemia
Sickle cell anemia may be diagnosed with hemoglobin electrophoresis.
Question 157
The nurse is preparing to perform an assessment on a new patient who is an infant. When considering which reflexes to assess, at what age should the walking/stepping reflex disappear?
  • 6 months
  • 12 months
  • 4 months
  • 2 months ✓
Correct Answer
2 months
The walking/stepping reflex disappears around 2 months of age.
Question 158
The nurse is caring for a pediatric client with a history of right-sided heart failure. Which of the following findings does the nurse anticipate?
  • Wheezing
  • Nasal flaring
  • Hepatomegaly ✓
  • Tachypnea
Correct Answer
Hepatomegaly
Hepatomegaly is a finding suggestive of right-sided heart failure. Tachypnea, wheezing, and nasal flaring are findings of left-sided heart failure.
Question 159
A nurse is caring for a school aged child who was recently diagnosed with ADHD. The nurse is providing family teaching. What should the nurse say when the parent asks, "What time of day should I give him his medicine?"
  • In the morning ✓
  • In the afternoon
  • In the evening
  • At bedtime
Correct Answer
In the morning
ADHD medication should be given in the morning to prevent insomnia.
Question 160
A child presents to the emergency department with a rash that started on their face and neck and has since spread to the rest of their body. What condition should the nurse suspect?
  • Parvovirus B19
  • Rubeola
  • Paramyxovirus
  • Rubella ✓
Correct Answer
Rubella
Rubella (i.e., German measles) typically presents with a rash that begins on the face and neck and spreads to the rest of the body afterwards.
Question 161
The nurse is providing parenting classes for local families. Which of the following terms describes a child's behavior of treating inanimate objects as though they are alive?
  • Animism ✓
  • Magical thinking
  • Artificialism
  • Pretend play
Correct Answer
Animism
Animism is the childhood belief that inanimate objects are capable of actions and lifelike qualities.
Question 162
A child presents to the emergency room and the nurse notes multiple injuries in various stages of healing. The nurse is aware that this finding may be consistent with which finding?
  • Physical abuse ✓
  • Legg-Calve-Perthes disease
  • Zollinger-Ellison syndrome
  • Neglect
Correct Answer
Physical abuse
A child who is being physically abused may have multiple injuries in various stages of healing.
Question 163
The nurse is preparing to admit a new client diagnosed with Fifth's disease. The nurse should initiate which type of precautions for this client?
  • Airborne
  • Droplet ✓
  • Contact plus
  • Contact
Correct Answer
Droplet
Droplet precautions are required for a child with Fifth's disease (i.e., parvovirus B19).
Question 164
A child states that they live at home with their mother, step-father, and half-sister, and step-brother. The nurse correctly identifies this as which type of family?
  • Blended ✓
  • Nuclear
  • Extended
  • Binuclear
Correct Answer
Blended
A blended family is made up of parents who have biological children from previous marriages.
Question 165
A nurse who typically works with adult clients is floating on a pediatric unit. Which of the following vital signs does the nurse need to recall is likely to be lower in a child than in an adult?
  • Pulse
  • Pulse oximetry
  • Blood pressure ✓
  • Respirations
Correct Answer
Blood pressure
The average blood pressure of children is lower than in adults.
Question 166
The nurse is hosting a parenting class for expecting parents. When reviewing parenting styles, which style is high control, low warmth, with inflexible rules and little communication?
  • Neglectful
  • Authoritarian ✓
  • Authoritative
  • Permissive
Correct Answer
Authoritarian
Authoritarian parenting style exhibits high control and low warmth with inflexible rules and little communication.
Question 167
The nurse is providing eduation to new parents about vaccine schedules. How often should the nurse recommend the influenza vaccine be administered?
  • Semiannually
  • Quarterly
  • Biannually
  • Annually ✓
Correct Answer
Annually
The influenza vaccine should be administered annually during flu season.
Question 168
The nurse suspects a child in the emergency department is suffering from rubella. Which isolation precautions should be implemented?
  • Droplet ✓
  • Contact plus
  • Airborne
  • Contact
Correct Answer
Droplet
Rubella (i.e., German measles) requires the use of droplet precautions.
Question 169
The nurse is admitting a newborn with a low-grade fever, high-pitched whooping cough, and cyanosis. The nurse should arrange which type of precautions for this patient?
  • Droplet precautions ✓
  • Airborne precautions
  • Contact precautions
  • No precautions needed
Correct Answer
Droplet precautions
This patient likely has pertussis which requires droplet precautions.
Question 170
A nurse measures a patient's blood pressure on the right arm and notes a high reading. The nurse decides to reassess by reading on the patient's leg. This reading shows low blood pressure. What could this result indicate?
  • Coarctation of the aorta ✓
  • Atrial Septal defect
  • Tetralogy of Fallot
  • Ventricular septal defect
Correct Answer
Coarctation of the aorta
Coarctation of the aorta affects upper extremity blood pressure because the blood has to work extra hard to fit through a constricted aorta.
Question 171
A nurse is caring for a newly admitted patient with suspected rheumatic fever. Which assessment should the nurse do first?
  • Abdominal palpation
  • Abdominal auscultation
  • Auscultation of heart sounds ✓
  • Deep tendon reflexes
Correct Answer
Auscultation of heart sounds
Cardiac assessment should be a priority because rheumatic fever can lead to rheumatic heart disease with carditis, regurgitation, or murmur.
Question 172
The nurse is providing care for a patient with cystic fibrosis. They can expect to administer which medication with the patient's meals and snacks?
  • Salmeterol
  • Amoxicillin
  • Dornase alfa
  • Pancrelipase ✓
Correct Answer
Pancrelipase
Pancrelipase is pancreatic enzymes which are given with meals and snacks to cystic fibrosis patients in order to help them digest food.
Question 173
What is the nurse's priority action when caring for a child with Wilms' tumor?
  • Measure blood pressure
  • Avoid abdominal palpation ✓
  • Abdominal auscultation
  • Assess WBC
Correct Answer
Avoid abdominal palpation
The nurse should avoid abdominal palpation in a child with Wilms' tumor as this can lead to a rupture of the encapsulated tumor.
Question 174
A nurse is caring for a patient with Hirschsprung's disease. Upon assessment the patient has a temperature of 101° F and diarrhea. What should the nurse do next?
  • Reassess the patient in an hour
  • Administer acetaminophen
  • Administer loperamide
  • Notify the provider ✓
Correct Answer
Notify the provider
The provider should be notified because fever and diarrhea are signs of enterocolitis, a life-threatening complication of Hirschsprung's disease.
Question 175
A nurse is providing patient teaching to a ten year old patient with celiac disease and their parents. What food can this patient safely consume?
  • Peanut butter sandwich on rye bread
  • Rice pudding ✓
  • Oatmeal
  • Whole wheat pasta
Correct Answer
Rice pudding
Any food containing gluten (e.g., wheat, rye, barley, oats) must be avoided with celiac disease. Rice pudding is a safe food for this patient to consume.
Question 176
The nurse is assessing a three month old child with developmental dysplasia of the hip wearing a pavlik harness. Which of the following findings should prompt the nurse to provide additional teaching to the parents?
  • The child's diaper is secured over the harness ✓
  • The child is wearing one diaper
  • The parents state they have not adjusted the harness
  • The child is wearing an undershirt
Correct Answer
The child's diaper is secured over the harness
The diaper should be worn under the straps of the harness. The other answers are all safe practices for a pavlik harness.
Question 177
A nurse is providing emergency care to a patient with a head injury. What is the priority action for the nurse?
  • Assess vital signs
  • Stabilize the cervical spine ✓
  • Check patient's orientation level
  • Assess for fluid in ear canal
Correct Answer
Stabilize the cervical spine
The priority is to stabilize the cervical spine, then maintain a patent airway. All other assessments and interventions can be done afterwards.
Question 178
A nurse is walking in the hallways with a child when they begin to seize. What is the priority action for the nurse?
  • Put the patient on their left side with their knees bent
  • Move any nearby furniture/objects
  • Lower the patient to the floor ✓
  • Loosen restrictive clothing
Correct Answer
Lower the patient to the floor
Lowering the patient is the priority action to prevent any injury from falls. The other answers are actions that should be taken after the patient is lowered to the floor.
Question 179
Which statement made by the caregiver of a child with strabismus indicates the need for further teaching?
  • We will place an eye patch on their weak eye. ✓
  • Because my child is three, we can expect restoration of their vision.
  • The eye patch will only be worn for a few hours each day.
  • Occlusion therapy will be used to treat my child's strabismus
Correct Answer
We will place an eye patch on their weak eye.
Occlusion therapy is used to treat strabismus, and involves placing a patch over the strong eye for a few hours (e.g., 6 - 12) per day. Young children (i.e., < 6 years old) who undergo treatment are likely to have restoration of their vision. The caregiver should NOT patch the affected eye.
Question 180
A nurse is providing care for a child with suspected epilepsy. The child is scheduled for an electroencephalogram the following day. Which patient teaching point should the nurse provide before this procedure?
  • Take all of your medications prior to the EEG
  • Get a full night's sleep the night prior to the EEG
  • Remain NPO for 8 hours prior to the EEG
  • Wash your hair prior to the procedure ✓
Correct Answer
Wash your hair prior to the procedure
The only correct teaching point is to wash their hair prior to the EEG. The patient should arrive sleep deprived, NPO is not necessary, and certain medications such as sedatives should be avoided prior to this procedure.
Question 181
A nurse is caring for a child who has frequent nosebleeds. The nurse assesses the parent's reaction to the child's nosebleed. Which action done by the parents should prompt the nurse to provide further teaching?
  • Tilts the child's head forwards
  • Pinches the soft part of the child's nose
  • Tilts the child's head backwards ✓
  • Applies ice to the bridge of the child's nose
Correct Answer
Tilts the child's head backwards
The child should not be tilted backwards as this can cause them to swallow blood. The other options are all appropriate treatments for a nosebleed.
Question 182
The nurse is instructing new parents on how to prevent sudden infant death syndrome (SIDS). What should the nurse include as the best way to put an infant to sleep in order to prevent SIDS?
  • Alone, on their stomach, in a crib.
  • On their back with a pillow supporting their head.
  • On their back with a blanket and toy for comfort.
  • Alone, on their back, in a crib. ✓
Correct Answer
Alone, on their back, in a crib.
Placing a baby alone, on their back, in a crib is the best way for them to sleep to avoid suffocation/overheating/SIDS.
Question 183
The nurse identifies a need for further education when the caregiver of a child recently diagnosed with cystic fibrosis states which of the following is a common finding?
  • Steatorrhea
  • Infertility
  • Frequent respiratory infections
  • Excessive salivation ✓
Correct Answer
Excessive salivation
Symptoms of cystic fibrosis include frequent respiratory infections, steatorrhea, and infertility, among others. Excessive salivation is not a symptom commonly associated with CF.
Question 184
A child who is not up to date on routine vaccinations presents to the emergency room in tripod position with a hoarse, muffled voice, drooling, and dysphagia. Which of the following actions should the nurse take?
  • Suction the child's oropharynx
  • Prepare for intubation ✓
  • Collect throat swabs for culture
  • Use a tongue depressor to visually assess the throat
Correct Answer
Prepare for intubation
An unvaccinated child with a hoarse, muffled voice, drooling, dysphagia, and tripoding is likely to be experiencing epiglottitis, a life threatening complication of Haemophilus influenzae type b. The nurse should avoid placing anything in the mouth, as this could lead to the loss of the child's airway. Securing the airway with intubation is the most important intervention.
Question 185
Which of the following findings should the nurse report to the provider in a child who is status-post tonsillectomy?
  • Pain felt in the ears and neck
  • Frequent clearing of the throat ✓
  • Throat pain rated 8/10
  • Patient can only tolerate clear liquids
Correct Answer
Frequent clearing of the throat
Frequent swallowing and/or clearing of the throat may indicate postoperative bleeding in a patient following tonsillectomy. Pain in the throat, ears, and neck is expected, and solid foods should be avoided for a few days following surgery.
Question 186
The nurse is caring for a patient post-op tonsillectomy. The patient is requesting a drink, which is the best choice to give this patient?
  • Cherry kool-aid
  • Hot tea
  • Pomegranate juice
  • Apple juice ✓
Correct Answer
Apple juice
A post-op tonsillectomy patient should avoid red food/drinks and hot items. Therefore, apple juice, a clear cool liquid is the best choice for this patient.
Question 187
A nurse is assessing a nine year old child. Which finding should the nurse report to the provider?
  • Can ride a bicycle
  • Permanent teeth are erupting
  • Sleeps six hours a night ✓
  • Eats three meals a day
Correct Answer
Sleeps six hours a night
A nine year old child should be sleeping approximately nine hours per night. The other findings are expected for a child of this age.
Question 188
A nurse is assessing a child who just began preschool. Which finding should the nurse report to the provider?
  • Grown three inches in a year
  • Experiences regular nightmares
  • Can ride a tricycle
  • Eight deciduous teeth ✓
Correct Answer
Eight deciduous teeth
Eruption of all twenty deciduous teeth is expected by the beginning of preschool, so the absence of this finding should be reported. The other findings are expected for a preschool aged child.
Question 189
A nurse is assessing a two year old patient. Which of these findings should they report to the provider?
  • Four times their birth weight
  • Sleeps 11 - 12 hours each day
  • Combines several words to create simple sentences
  • An open anterior fontanelle ✓
Correct Answer
An open anterior fontanelle
The anterior fontanelle should close by 18 months old. The other findings are normal for a 2 year old.
Question 190
While preparing to administer a vaccine to a child, the nurse notes a low-grade fever. What should the nurse do?
  • Administer half the normal volume of the vaccine
  • Reschedule the child's appointment for a month in the future
  • Call the provider
  • Administer the vaccine ✓
Correct Answer
Administer the vaccine
A low-grade fever is not a contraindication to receiving a childhood vaccination. The nurse should continue with vaccine administration.
Question 191
A nurse is preparing to give a newborn their first vaccine. Which vaccine should the nurse prepare?
  • Hepatitis B ✓
  • Influenza
  • Varicella
  • Hepatitis A
Correct Answer
Hepatitis B
Hepatitis B is given at birth along with erythromycin ophthalmic ointment and a vitamin K shot.
Question 192
A nurse is assessing a two month old infant following surgery. Which pain scale should the nurse use for this patient?
  • Oucher
  • Wong-Baker faces
  • FLACC ✓
  • Numeric
Correct Answer
FLACC
FLACC is appropriate for this patients age. The other options are more appropriate for older children.
Question 193
The nurse is caring for an alert and oriented child whose mother reports ingested bleach about 30 minutes ago. What is the nurse's priority action?
  • Call poison control ✓
  • Induce vomiting with ipecac syrup
  • Prepare for intubation
  • Have the child drink 8 fl oz of milk
Correct Answer
Call poison control
The nurse should immediately contact poison control before taking any further action.

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