CMA Review Flashcards
(152 cards)
1
Q
A nurse is preparing to assess a 4-year-old child’s visual acuity. Which of the following actions should the nurse plan first?
A. Use a tumbling E chart for the assessment
B. Position the child 4.6 meters (15 feet) from the chart
C. Asses both eyes together first, then each eye separately
D.Test the child without glasses before testing with glasses
A
A. Use a tumbling E chart for the assessment
2
Q
A nurse is providing discharge teaching to a parent of a child who has juvenile idiopathic arthritis and a new prescription of prednisone/etanercept. Which of the following statements should the nurse include in the teaching?
A. Monitor your child for indications of infection
B. Discontinue this medication if gastrointestinal upset occurs
C. Expect that this medication will stimulate growth spurt
D. Limit your child’s intake of potassium-rich foods
A
A. Monitor your child for indications of infection
3
Q
A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?
A. An adolescent who has hepatitis A
B. A toddler who has seasonal influenza
C. A preschool-age child who has pediculosis capitis
D. A school-age child who has viral conjunctivitis
A
B. A toddler who has seasonal influenza
4
Q
A nurse is providing teaching to an adolescent who has vulvovaginitis. Which of the following statements should the nurse include in the teaching?
A. Apply a warm, moist compress three times a day
B. Apply a scent baby powder to absorb residual moisture
C. Wear a feminine deodorant pad for vaginal drainage
D. Wear a nylon underwear at night
A
A. Apply a warm, moist compress three times a day
5
Q
A nurse is caring a plan of care for a school-age child who has nephrotic syndrome. Which of the following interventions should the nurse include?
A
-provide a low sodium diet
-assess for protein in the urine
-obtain a daily weight
6
Q
A nurse is providing postoperative care for a child following an arterial cardiac catheterization. Which of the following actions should the nurse take?
A. Remove the child’s pressure dressing after the first 4 hours.
B. Maintain the child’s NPO status for 4 to 6 hours.
C. Keep the affected extremity straight for at least 6 hours.
D. Monitor output using an indwelling urinary catheter for the first 24 hours.
A
C. Keep the affected extremity straight for at least 6 hours.
7
Q
A nurse is teaching a parent of a toddler about administering digoxin. Which of the following statements by the parent indicates an understanding of the teaching?
A. I should give the medication with 4 ounces of my child’s favorite juice
B. I should give my child water after giving the medication
C. I should give the medication with foods that are high in fiber
D. I should give my child another dose if he vomits right after taking the medication
A
B. I should give my child water after giving the medication
8
Q
A nurse is caring for a 9-year-old child who has a major burn to her face and upper torso. Which of the following actions should the nurse take first?
a.Administering a tetanus vaccine
b.Give pain medication
c.Begin enteral feeding
d.Initiate a crystalloid bolus
A
b.Give pain medication
9
Q
A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care?
A. Moisten the mucosa with lemon glycerin swabs.
B. Cleanse the gums with saline soaked gauze.
C. Administer oral viscous lidocaine.
D. Schedule routine oral care ever hr.
A
B. Cleanse the gums with saline soaked gauze.
10
Q
A nurse in a community health clinic is assessing the needs of a single parent who has three young children and works full time. Which of the following resources should the nurse recommend?
A. 12-step support group
B. Respite child-care
C. Child home health care
D. Counseling for depression
A
B. Respite child-care
11
Q
A nurse is caring for a child who has prescription for fluticasone and has developed white patches and sores in his mouth. Which of the following is an appropriate action for the nurse to take?
A. Encourage the use of a spacer
B. Withhold the medication until the lesions heal
C. Obtain a prescription for oral prednisone
D. Collect a culture from the lesions
A
D. Collect a culture from the lesions
12
Q
A nurse is providing teaching to the parents of a child who has impetigo. Which of the following instructions should the nurse include in the teaching?
A. Seal soft toys in a plastic bag for 14 days
B. Apply bacterial ointment for lesions
C. Administer acyclovir PO two times per day
D. Soak hair brushes in boiling water for 10 minutes
A
B. Apply bacterial ointment for lesions
13
Q
A nurse in an emergency department is caring for a child who is epiglottitis. Which of the following actions should the nurse take?
A. Provide nebulizer aerosol therapy
B. Administer IV antibiotics
C. Inspect the tonsils using a tongue depressor
D. Collect a throat culture
A
A. Provide nebulizer aerosol therapy
14
Q
A nurse is planning care for a child who is placed in skin traction. Which of the following is the priority action for the nurse to take?
a. Maintain proper body alignment
b. Use an alternate pressure mattress
c. Monitor pedal pulses
d. Increase fluid intake
A
a. Maintain proper body alignment
15
Q
A nurse is performing a physical assessment of a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
A. Hypotension
B. Increased urinary output
C. Flushed skin
D. Facial edema
A
D. Facial edema
16
Q
A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline.
Which of the following findings should the nurse expect?
A. Ataxia.
B. Hypothermia.
C. Hyperactive reflexes.
D. Pinpoint pupils.
A
A. Ataxia.
17
Q
A nurse in the emergency department is assessing a toddler who has hyperpyrexia, severe dyspnea, and is drooling.
Which of the following actions should the nurse take first?
A. Administer an antibiotic to the toddler.
B. Obtain a blood culture from the toddler.
C. Insert an IV catheter for the toddler.
D. Prepare the toddler for nasotracheal intubation.
A
D. Prepare the toddler for nasotracheal intubation.
18
Q
A nurse is caring for an infant who has hydrocephalus and ventriculoperitoneal shunt malfunction. Which of the following assessment findings indicates that the infant is experiencing increased intracranial pressure?
A. Increased appetite
B. Irritability
C. Flat fontanel
D. Tachycardia
A
B. Irritability
19
Q
A nurse is assessing an infant who has iron deficiency anemia. Which of the following findings should the nurse expect?
a. Pale conjunctiva
b. Increased hemoglobin level
c. Bradycardia
d. Hyperactive muscle tone
A
a. Pale conjunctiva
20
Q
A nurse is caring for a child who received partial-thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following actions should the nurse take? (Select all that apply.)
A. Provide a high-calorie diet
B. Monitor intake and output.
C. Change dressings using aseptic technique
D. Remove splints during sleep
E. Administer analgesics IM
A
A. Provide a high-calorie diet
B. Monitor intake and output.
C. Change dressings using aseptic technique
21
Q
A school nurse is assessing a 7-year-old student.
The nurse should identify which of the following findings as a potential indicator of physical abuse?
A. Weight in 45th percentile.
B. Abrasions on the knees.
C. Bruising around the wrists.
D. Front deciduous teeth missing.
A
C. Bruising around the wrists.
22
Q
A nurse is assessing an 18-month-old child during a well-child visit. Which of the following findings should the nurse report to the provider?
A. The child crawls to navigate the room
B. The child has frequent temper tantrums
C. The child consistently throws items to the floor
D. The child scribbles on the wall with a crayon
A
A. The child crawls to navigate the room
23
Q
A nurse is caring for an infant who has rotavirus.
Which of the following findings indicates that the infant is moderately dehydrated?
A.Respiratory rate 28/min.
B.Capillary refill 1 second.
C.Weight loss 7%.
D.Bradycardia.
A
C.Weight loss 7%.
24
Q
A nurse is providing teaching about injury prevention to the parents of a toddler. Which of the following safety measures should the nurse include in the teaching?
A. Check clothing for loose buttons.
B. Adjust the water heater temperature to 54° C (129.2° F).
C. Place screens on all windows.
D. Provide balloons for play.
A
A. Check clothing for loose buttons.
25
A nurse is caring for a school-aged child who is in 90/90 skeletal traction. following actions should the nurse take?
A. Release the traction to allow the child to bathe
B. Place the child on an alternating pressure mattress
C. Adjust the weights to allow the child to turn
D. Ensure that the pulley mechanism is attached to the skin
B. Place the child on an alternating pressure mattress
26
A nurse is caring for a child who has increased intracranial pressure and is unconscious due to a closed head injury. Which of the following acons should the nurse take?
A. Maintain the child’s neck in an flexed position
B. Turn the child side to side every 2 hours
C. Initiate seizure precautions
D. Perform chest percussion as needed
C. Initiate seizure precautions
27
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?
A.Clear the area of hard objects.
B.Minimize movement of the limbs.
C.Insert a tongue blade between the teeth.
D.Place the child in a prone position.
A.Clear the area of hard objects.
28
A nurse is providing teaching to a parent of an infant who has diaper rash. Which of the following statements by the parent indicates an understanding of the teaching?
a. I will keep the area warm and moist.
b. I will use antibacterial soap to wash the rash with each diaper change.
c. I will use super absorbent disposable diapers
d. I will sprinkle talcum powder over the affected area twice daily.
c. I will use super absorbent disposable diapers
29
A nurse in a provider's office is assessing the vital signs of a 1-year-old toddler. Which of the following findings should the nurse report to the provider?
a. blood pressure 88/42 mmHg
b. heart rate 110/min
c. respiratory rate 54/min
d. temperature 37.7 C (99.9 F)
c. respiratory rate 54/min
30
A nurse is teaching about growth and development to a parent of a 12-year-old child. The nurse should instruct the parent to expect the child to exhibit which of the following characteristics during early adolescence?
A.Increased self-esteem
B.Mood swings
C.Decelerating growth rate
D.Emotional separation from parents
B.Mood swings
31
A nurse is caring for a child who is 2 hours postoperative. Which of the following actions should the nurse take first?
a. recheck the child's temperature
b. determine the child's sedation level
c. assess the child's pain level
d. compare the child's pedal pulses
c. assess the child's pain level
32
A nurse is assessing an adolescent who has Cushing's syndrome. Which of the following findings should the nurse expect?
a. potassium 4.2 mEq/L
b. blood glucose 320 mg/dL
c. advanced bone age
d. cachectic appearance
b. blood glucose 320 mg/dL
33
A nurse is caring for a preschool-age child who is 2 hours postoperative following a tonsillectomy and adenoidectomy. Which of the following manifestations should the nurse report to the provider?
a. tachycardia
b. blood-tinged mucus
c. dark brown emesis
d. halitosis
b. blood-tinged mucus
34
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should immediately report which of the findings to the provider?
a. coughing
b. tachypnea
c. pharyngitis
d. rhinorrhea
b. tachypnea
35
A nurse is admitting an infant who has GERD. Which of the following is the priority
assessment finding?
a. weight loss
b. excessive crying
c. wheezing
d. regurgitation
c. wheezing
36
A nurse is planning care for a child who is experiencing sickle cell crisis. Which of the following interventions should the nurse include in the plan of care?
a. administer meperidine as needed for pain
b. initiate bed rest
c. limit fluid intake
d. apply cold compresses to affected joints
b. initiate bed rest
37
A nurse is providing teaching to a parent of a child who has cystic fibrosis and a new prescription for dornase alfa. Which of the following instructions should the nurse include in the teaching?
a. Store the medication in the refrigerator
b. Use this medication
c. Administer Every four hours as needed for cough
D. Mix the medication with albuterol solution prior to administration
a. Store the medication in the refrigerator
38
A nurse is caring for a preschool-age-child who has a terminal illness. Which of the following findings should the nurse expect?
a. Believe the condition of the punishment
b. Expresses interest in the funeral arrangements
c. Accepts death is inevitable
d. Feels excessive anxiety about physical changes
a. Believe the condition of the punishment
39
A nurse is reviewing the laboratory values of a school-age child who has nephrotic syndrome. Which of the following laboratory results should the nurse expect?
a. serum sodium 144 mg/dL
b. serum protein 4.2 g/dL
c. Hgb 12 g/dL
d. BUN 15 mg/dL
b. serum protein 4.2 g/dL
40
A nurse is planning care for a school-age child who has autism spectrum disorder. Which
of the following actions should the nurse include in the plan?
a. Get the child three options when making choices
b. Stay with the child for long periods of time
c. Explain procedures in detail to the child
d. Introduce the child to new situations slowly
d. Introduce the child to new situations slowly
41
A nurse is providing teaching to a parent of an 11-month-old infant who has acute diarrhea and dehydration. Which of the following fluids should the nurse instruct the parent to provide to the infant?
a. Chicken broth
b. Oral electrolytes solution
c. Glucose water
d. Half-strength apple juice
b. Oral electrolytes solution
42
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
a. The risk of transmission decreases and my child is on zidovudine for 2 weeks
b. My child will need to repeat his childhood immunizations since he is in remission
c. My child will need to double his medication's for the next six months
d. I will ensure that my child is tested for tuberculosis every year
b. My child will need to repeat his childhood immunizations since he is in remission
43
A nurse is caring for a school-age child who has diabetes mellitus. Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
a. pallor
b. thirst
c. sweating
d. tremors
b. thirst
44
A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?
a. A preschool age child who has muffled voice and spontaneous cough
b. And adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lbs)
c. A toddler who has nephrotic syndrome and facial edema
d. A school age child who has diabetes mellitus and a blood glucose of 200 mg/dL
a. A preschool age child who has muffled voice and spontaneous cough
45
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?
a. An adolescent who has sickle cell anemia and slurred speech
b. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
c. And adolescent who is in traction and report a pain level seven on a scale from 0 to 10
d. A toddler who has a partial thickness burn on his right hand and requires a dressing change
a. An adolescent who has sickle cell anemia and slurred speech
46
A nurse is preparing to administer immunization to a 3-month-old infant. Which of the
following is an appropriate method to take to deliver atraumatic care?
a. Use a 20 gauge needle for the injection
b. Apply eutectic mixture of anesthetics (EMLA) immediately before the injections
c. Inject immunization into the deltoid muscle
d. Provide a pacifier coated with an oral sucrose prior to the injections
d. Provide a pacifier coated with an oral sucrose prior to the injections
47
A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should expect that which of the following laboratory tests can contribute to confirming this diagnosis? (SATA)
a. Antistreptolysin O (ASO) titer
b. blood urea nitrogen (BUN)
c. partial thromboplastin (PTT)
d. Erythrocyte sedimentation rates (ESR)
e. C-reactive protein (CRP)
a. Antistreptolysin O (ASO) titer
d. Erythrocyte sedimentation rates (ESR)
e. C-reactive protein (CRP)
48
A nurse is reviewing the laboratory report of a school-age child who has bacterial pneumonia. Which of the following laboratory values should the nurse expect?
a. WBC 18,000/mm3
b. pH 7.40
c. Hgb 14 g/dL
d. Creatinine 0.5 mg/dL
a. WBC 18,000/mm3
49
A nurse is providing teaching about medication administration to the parents of a toddler who has a new prescription for liquid ferrous sulfate. Which of the following instructions should the nurse include in the teaching?
a. Report tarry, green stools to the provider
b. Administer the drops with milk
c. Dilute with water prior to the administration
d. Provide an antacid prior to administration
c. Dilute with water prior to the administration
50
A nurse in an emergency department is caring for a child following an overdose of acetylsalicylic acid. Which of the following medications should the nurse plan to administer?
a. flumazenil
b. phytonadione
c. midazolam
d. naloxone
b. phytonadione
51
A nurse is planning care for a newly admitted child who has rotavirus. Which of the following precautions should be implemented?
a. airborne
b. contact
c. protective
d. droplet
b. contact
52
A nurse is developing a plan of care for child who is dying. Which of the following measures should the nurse implement to the child and his family?
a. Maintain consistent nursing staff assignments
b. Ask the parents to leave the room for the procedures
c. Select one family member to receive information
d. Limit the number of visitors in the clients room
a. Maintain consistent nursing staff assignments
53
A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?
a. Have the child flex his head when securing the ties
b. Place the child in Trendelenburg position when performing care
c. Clean around the stoma with full strength hydrogen peroxide
d. Use clean technique to change the tracheostomy tube
a. Have the child flex his head when securing the ties
54
A nurse in the emergency department is caring for a child who has a temperature of 39.1 C (102.4 F) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?
a. Prepare a child for a lumbar puncture
b. Administer an antipyretic to the child
c. Dim the lights in the child's room
d. Implement droplet precautions for the child
d. Implement droplet precautions for the child
55
A nurse is caring for a toddler who has a shirt leg cast. Which of the following findings should the nurse report to the provider?
a. Positive pedal pulse in the distal extremity
b. Pallor of the distal extremity
c. Mobility of the distal extremity
d. Warm temperature of the distal extremity
b. Pallor of the distal extremity
56
A nurse is caring for a newly admitted toddler who has acute diarrhea. Which of the following actions should the nurse take first?
a. Initiate contact precautions
b. Administer an antibiotic
c. Obtain a stool specimen for culture
d. Give 0.9% sodium chloride bolus
a. Initiate contact precautions
57
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?
a. You may tolerate plain milk better than chocolate milk
b. You can drink milk on an empty stomach
c. You can replace milk with nondairy sources of calcium
d. You should consume flavored yogurt instead of plain yogurt
c. You can replace milk with nondairy sources of calcium
58
A nurse is providing discharge teaching to the parents of a school-age child following placement of a ventriculoperitoneal shunt. The nurse should determine that the teaching was effective when the parents identify which of the following as an indication the shunt has been displaced?
a. Hyper active bowel sounds
b. Elevated temperature
c. Increased sleeping
d. Decreased urine output
b. Elevated temperature
59
A nurse is providing teaching to a parent of a 2-month-old infant about immunization schedules. Which of the following statements by the parent indicates an understanding
of the teaching?
a. My child needs to get the MMR immunization when she's 12 months old
b. My child needs to get the varicella immunization when she's 6 months old
c.
My child will receive the influenza immunization today
d. My child will receive the hepatitis A immunization today
a. My child needs to get the MMR immunization when she's 12 months old
60
A nurse is performing a cranial nerve assessment on a school-age child. Which of the following findings indicates proper functioning of the child's trigeminal nerve?
a. A child maintain balance when standing with eyes closed
b. The child has symmetrical jaw strength when biting down
c. A child exhibits a gag reflex when stimulated with a tongue blade
d. The child correctly identify specific exams
b. The child has symmetrical jaw strength when biting down
61
A nurse is planning care for a child immediately following the insertion of a chest tube for continuous suction closed drainage system. Which of the following interventions should the nurse include in the plan of care?
a. Ensure continuous bubbling is present in the suction control chamber
b. Report the presence of tidaling of fluid in the water seal chamber
c.
Change the chest tube insertion site tracking every 12 hours
d. Record the amount of chest tube drainage every two hours
a. Ensure continuous bubbling is present in the suction control chamber
62
A nurse is educating an adolescent following the application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?
a. I will sprinkle baby powder into the cast if my arm itches
b. I should limit the use of my fingers of my broken arm
c. I will elevate my forearm on pillows at night
d. I should expect my fingers to be swollen for several days
c. I will elevate my forearm on pillows at night
63
A nurse in a community center is providing an in-service for parents about nutritional guidelines. Which of the following guidelines should the nurse include in the teaching?
a. Encourage a 15-year-old to increase calcium intake
b. Provide 35 ounces of milk per day to a toddler
c. Offer 8 to 10 ounces and two per day to a preschooler
d. Introduced popcorn as a healthy snack at 12 months of age
a. Encourage a 15-year-old to increase calcium intake
64
A nurse is caring for a school-aged child who is experiencing pain. Which of the following assessment teachings would be the most accurate information regarding the child's pain?
a. Ask the child to use a FACES rating scale
b. Monitor the child's involuntary movements
c. Observe the child's facial expressions
d. Assess the child's pulse and respiration
a. Ask the child to use a FACES rating scale
65
A nurse in an emergency department is assessing a school-age child who has asthma. Which of the following should the nurse identify as the priority?
a. decreased breath sounds
b. Hyper resonance on percussion
c. Nonproductive cough
d. Pulse rate 118/min
a. decreased breath sounds
66
A nurse is caring for a child who is postoperative following surgical correction of tetralogy of Fallot. Which of the following is a manifestation of heart failure?
a. exercise intolerance
b. bradycardia
c. weight loss
d. decreased respirations
b. bradycardia
67
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamycin. Which of the following laboratory results should the nurse report to the provider?
a. creatinine 1.4 mg/dL
b. BUN 12 mg/dL
c. BUN 6 mg/dL
d. creatinine 0.2 mg/dL
a. creatinine 1.4 mg/dL
68
A nurse is providing teaching to guardians off a school-aged child who has a seizure disorder. Which of the following factors should the nurse include as a common trigger that increases the risk of seizures?
a. prolonged headache
b. lack of sleep
c. decreased temperature
d. exposure to secondhand smoke
a. prolonged headache
69
A nurse planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?
a. Place the infant in a prone position
b. Repeat a digoxin dosage is the infant vomiting within one hour of administration
c. Provide frequent, higher volume feedings
d. Administer cool, humidified oxygen via nasal cannula
d. Administer cool, humidified oxygen via nasal cannula
70
A nurse is caring for an adolescent who is 1 hour postoperative following an appendectomy which of the following findings should the nurse report to the provider?
a. Temperature 36.4 C (97.5 F)
b. Muscle rigidity
c. Abdominal pain
d. Heart rate 63/min
b. Muscle rigidity
71
A nurse is providing teaching about the effects of sun exposure to a parent of a toddler. Which of the following responses by the parent indicates an understanding of the teaching?
a. My child should remain under a beach umbrella during morning hours
b. My child should wear a wide-brimmed hat
c. I should apply a 10 SPF sunscreen to my child's entire body
d. I should dress my child in loose-weave clothing
b. My child should wear a wide-brimmed hat
72
A nurse is reviewing the laboratory results of a preschooler who has gastroenteritis and notes the child's potassium level is 3.2 mEq/L. which of the following assessment findings should the nurse expect?
a. Oliguria
b. Hyperactive bowel sounds
c. Hypertension
d. Hyporeflexia
d. Hyporeflexia
73
A nurse is assessing a school age child's cranial nerve function. Which of the following actions should the nurse assess the child to take when assisting the accessory nerve?
a. Show their teeth while smiling
b. Shrug their shoulders against mild pressure
c. Move their tongue in all directions
d. Follow a light in the six cranial positions
b. Shrug their shoulders against mild pressure
74
A nurse is teaching a group of female adolescents about health eatng. Which of the following instructions should the nurse include in the teaching?
a. Consume 1500 to 1700 cal per day
b. Limit your sodium intake to at 3000 mg per day
c. Decrease your vitamin D intake once you start to menstruate
d. Increase the amount of your dietary iron intake
d. Increase the amount of your dietary iron intake
75
A nurse in a provider's office is preparing to administer immunizations to a 12-year-old client during a well child visit. Which of the following immunizations should the nurse plan to administer? SATA
a. Human papillomavirus (HPV)
b. Hepatitis A
c. Diphtheria, tetanus, & pertussis (DTaP)
d. Varicella
a. Human papillomavirus (HPV)
c. Diphtheria, tetanus, & pertussis (DTaP)
76
A nurse is assessing a school age child who has heart failure and is taking furosemide. Which of the following findings should the nurse identify as an indication that the medication is effective?
a. A decrease in peripheral edema
b. An increase in venous pressure
c. A decrease in cardiac output
d. An increase in potassium levels
a. A decrease in peripheral edema
77
A nurse is teaching home care to the parents of a preschool-age child who has heart failure. Which of the following information should the nurse include in the teaching?
a. Increase the child's oxygen flow rate until the child no longer has cyanosis
b. Withhold the digoxin is the child's pulse is greater than 100/min
c. Provide periods of rest
d. Weigh the child once a month
c. Provide periods of rest
78
A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
a. Initiate airborne precautions
b. Administer aspirin for fever
c. Provide the child with a warm blanket
d. Assess the oral cavity for Kolpik spots
a. Initiate airborne precautions
79
A nurse in the emergency department is assessing a toddler with hyperpyrexia, severe dyspnea, and drooling. Which of the following action should the nurse take first?
a. Prepare the toddler for nasal tracheal intubation
b. Administer that antibiotic to the child
c. Insert an IV catheter for the toddler
d. Obtain a blood culture on the toddler
a.
Prepare the toddler for nasal tracheal intubation
80
A nurse in a pediatric clinic is providing teaching to the guardian of an infant who has a new prescription for digoxin. Which of the following manifestation should the nurse include as an indication for digoxin toxicity?
a. polyuria
b. diaphoresis
c. jaundice
d. bradycardia
d. bradycardia
81
A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following action should the nurse take first?
a. Apply lidocaine gel to the perineum before attaching the bag
b. Position the opening of the bad over the urethra and the anus
c. Place a snug fitting diaper over the drainage bag
d. Stretch the perineum taut when applying the bag
d. Stretch the perineum taut when applying the bag
82
A nurse is caring for a school age child following the application of a cast to a fractured right tibia. Which of the following actions should the nurse take first?
a. Administer pain medication
b. Elevate the child's leg
c. Palpate the edges of the cast
d. Teach the child about cast care
b. Elevate the child's leg
83
A nurse is preparing to administer prescribed medication to a toddler whose parent is nearby. Which of the following actions should the nurse take to identify the toddler?
a. Ask another nurse to confirm the child's identity
b. Check the toddler's ID band against medical record
c. Ask a parent to confirm the toddler's identity
d. Check the toddlers room number against their ID bracelet
b. Check the toddler's ID band against medical record
84
A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which
of the following findings should the nurse expect?
a. Increased urine output
b. Increased respiratory rate
c. Capillary refill of 2 seconds
d. Hypertension
b. Increased respiratory rate
85
A nurse is caring for a three-month-old infant who has a clean of soft palate. Which of the following actions should the nurse take?
a. Postpone burping the infant until after completing each feeding
b. Feed the infant 177.4 mL (6 oz)of formula 3 times each day
c. Discontinue feeding if the client's eyes become watery
d. Elevator infant to a 10° angle during feedings
c. Discontinue feeding if the client's eyes become watery
86
A nurse is providing teaching about home care to the parents of a child who has scabies. Which of the following instructions should the nurse include in the teaching?
a. Apply petroleum jelly to the affected areas
b. Soak combs and brushes in boiling water for 10 min
c. Treat everyone who came into close contact with the child
d. Wash the child's hair with shampoo containing ketoconazole
c. Treat everyone who came into close contact with the child
87
A nurse is planning care for a child who has osteomyelitis. Which of the following interventions should the nurse include in the plan of care?
a. Initiate contact precautions for the child
b. Maintain a patent intravenous catheter
c. Encourage frequent physical activity to increase bone mass
d. Provide a high calorie, low protein diet
b. Maintain a patent intravenous catheter
88
A nurse is assisng an infant who has acute otitis media. Which of the following findings should the nurse expect? (SATA)
a. fever
b. increased appetite
c. crying
d. enlarged sub clavicular lymph node
e. restlessness
a. fever
c. crying
d. enlarged sub clavicular lymph node
e. restlessness
89
A nurse is admitting a child who has acute epiglottis. Which of the following actions should the nurse take?
a. Obtain a throat culture
b. Assist the child into supine position
c. Check oxygen saturation every four hours
d. initiate droplet isolation precaution
d. initiate droplet isolation precaution
90
A nurse in a provider's office is assisting the vital signs of a two-year-old child at a well child visit. Which of the following findings should the nurse report to the provider?
a. Blood pressure 118/74 mm Hg
b. Respiratory rate 26/min
c. Temperature 37.2 (99 F)
d. Pulse rate 98/min
a. Blood pressure 118/74 mm Hg
91
A nurse is providing teaching to a 10-year-old child who is scheduled for an arterial cardiac catheterization. Which of the following information should the nurse include in the teaching?
a. You will have your dressing removed 12 hours after the procedure
b. You will need to keep your leg straight for 8 hours following the procedure
c. You will be on bedrest for two days after the procedure
d. You will be on clear liquid diet for 24 hours following the procedure
b. You will need to keep your leg straight for 8 hours following the procedure
92
A nurse in an emergency department is caring for a preschool age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?
a. Hyperpyrexia
b. Polyuria
c. Neck vein distention
d. Jaundice
a. Hyperpyrexia
93
A nurse is reviewing the medical record of a 15-month-old child who is scheduled to receive the measles, mumps, and rubella (MMR) vaccine. Which of the following findings should the nurse identify as a contraindication of receiving this vaccine?
a. Temperature 37.2 (99 F)
b. Upper respiratory infection 2 days ago
c. Allergy to neomycin
d. Family history of seizures
c. Allergy to neomycin
94
A nurse is planning care for a 6-month-old infant who has bacterial meningitis. Which of the following interventions should the nurse include in the plan of care?
a. Keep the television on in the room to provide background noise
b. Provide frequent range of motion to the neck and shoulders
c. Pad the side rails of the crib
d. Place the infant in a semi private room
c. Pad the side rails of the crib
95
A nurse is providing teaching to the parents of an infant who is to undergo pilocarpine iontophoresis testing for cystic fibrosis. Which of the following statements should the nurse include in the teaching?
a. The test will measure the amount of chloride in your baby's sweat
b. We will measure the amount of protein in your baby's urine over 24 hour period
c. A nurse will insert an IV prior to the test
d. Your baby will need to fast for eight hours prior to the test
a. The test will measure the amount of chloride in your baby's sweat
96
A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury. Which of the following actions should the nurse take first?
a. Check pupil reactions
b. Inspect for fluid leaking from the ears
c. Examine scalp for lacerations
d. Assess respiratory status
d. Assess respiratory status
97
A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?
a. Exhibit a head lag when pulling to a sitting position
b. Absent gag reflex
c. Unable to roll from back to abdomen
d. Unable to hold a bottle
a. Exhibit a head lag when pulling to a sitting position
98
A nurse in a PACU is caring for a school-age child immediately following a tonsillectomy. Which of the following actions should the nurse take?
a. Offer the child ice cream when alert
b. Place the child in a side-lying position
c. Encourage the child to take deep breath and cough
d. Instruct the child to drink fluids through a straw
b. Place the child in a side-lying position
99
A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden death syndrome (SIDS). Which of the following statements by the parent indicates and understanding of the teaching?
a. I will have my baby sleep next to me in bed during the night
b. I will move my babies stuffed animal to the corner of her crib when she sleeps
c. I will dress my baby in lightweight clothing to sleep
d. I will lay my baby on her side to sleep for naps
c. I will dress my baby in lightweight clothing to sleep
100
A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?
a. Use half-strength formula when feeding the infant
b.
Assign consistent nursing staff to care for the infant
c. Keep the infant in initially stimulating environment
d. Give the infant fruit juice between feedings
a. Use half-strength formula when feeding the infant
101
A nurse is doing an evaluation of a 4-year-old child who has cystic fibrosis and has been receiving chest physiotherapy treatments. The nurse should identify which of the following findings as an indication that the therapy has been effective?
a. Increased urine output
b. Increased expectoration
c. Increased heart rate
d. Reduced pain
b. Increased expectoration
102
A nurse is caring for a preschooler who refuses to take a stat dose of oral diphenhydramine. Which of the following statements should the nurse make?
a. The medication will treat your hypersensitivity reaction
b. Sometimes when a child has to take medicine they feel sad
c. Let me know when you want to take the medication
d. Medication isn't bad it taste like candy
a. The medication will treat your hypersensitivity reaction
103
A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
a. Increased blood pressure
b. Bradycardia
c. Limb withdrawal
d. Relaxed facial expression
d. Relaxed facial expression
104
A nurse is providing support to a family whose infant died from sudden infant death syndrome (SIDS). Which of the following actions should the nurse take?
a. Avoid discussing details of the attempt to revive the infant
b. Provide a follow up phone call one week following the infant's death
c. Acknowledge the family members feelings of guilt
d. Discourage the parents from allowing siblings to view the body
c. Acknowledge the family members feelings of guilt
105
A nurse is teaching a group of parents about childhood immunizations. The nurse should identify that the infant should receive the first dose of which of the following immunizations at 12 months of age?
a. Human papillomavirus
b. Hepatitis B
c. Varicella
d. Inactivated Polio virus
d. Inactivated Polio virus
106
A nurse is caring for a school-age child who is 1 hour postoperative following a tonsillectomy. Which of the following actions should the nurse take? (SATA)
a. Administered an analgesic to the child on a scheduled basis
b. Maintain the child in supine position
c. Provide cranberry juice to the child
d. Observe the child for frequent swallowing
e. Discourage the child from coughing
a. Administered an analgesic to the child on a scheduled basis
d. Observe the child for frequent swallowing
e. Discourage the child from coughing
107
A nurse is communicating with a child who has hearing loss. Which of the following actions should the nurse take?
a. Exaggerate the pronunciation of words
b. Use light tough when initiating conversation
c. Maintain a neutral facial expression when speaking to the child
d. Change positions frequently to maintain the child's attention
b. Use light tough when initiating conversation
108
A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning. Which of the following information should the nurse include in the teaching?
a. Increase the toddlers protein consumption
b. Avoid foods containing milk products
c. Limit foods high in iron
d. Use aspartame as a sugar substitute
b. Avoid foods containing milk products
109
A nurse is assessing a toddler who has a history of lead poisoning. Which of the following actons should the nurse take?
a. Obtain a stool specimen for lead levels
b. Inspect the skin for discoloration
c. Perform developmental testing for delays
d. Initiate a low iron diet for lead absorption
c. Perform developmental testing for delays
110
A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the following actions should the nurse take?
a. Decrease the child fluid intake
b. Administer furosemide IV twice per day
c. Apply warm compresses to the affected areas
d. Initiate contact precautions
c. Apply warm compresses to the affected areas
111
A nurse is assessing a child who has multiple closed fractures of the lower extremities due to a motor-vehicle accident. The nurse should monitor the child for which of the following complications during the first 24 hours after the injury occurred?
a. Compartment syndrome
b. Renal calculi
c. Osteomyelitis
d. Volkmann ischemic contracture
a. Compartment syndrome
112
A nurse is teaching the guardian of a 5-year-old child who has encopresis about management of the condition. Which of the following statements by the guardian indicates an understanding of the teaching?
a. I will have my child try to defecate 15 minutes after each meal
b. I will increase my child dairy intake
c. I will have my child to sit on the toilet for 20 minutes at a time
d. I will limit my child fluid intake
a. I will have my child try to defecate 15 minutes after each meal
113
A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan?
a. Pneumococcal conjugate (PCV13)
b. Rotavirus
c. Respiratory syncytial virus (RSV)
d. Measles, mumps, rubella (MMR)
a. Pneumococcal conjugate (PCV13)
114
A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication. Which of the following actions should the nurse take first?
a. Administer epinephrine
b. Administer oxygen
c. Administer methylprednisolone
d. Administer a nebulized bronchodilator
a. Administer epinephrine
115
A nurse in an emergency department is caring for a child who has experienced a submersion injury. Which of the following is the priority action for the nurse to take?
a. Obtain an ABG sample
b. Administer IV bolus
c. Apply warming blankets
d. Assist with intubation
d. Assist with intubation
116
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?
a. HbA1c 11.5%
b. Glycosuria
c. Pre-prandial blood glucose 124 mg/dL
d. Cholesterol 189 mg/dL
a. HbA1c 11.5%
117
A nurse is planning to administer immunizations to a 2-month-old infant. Which of the following actions should the nurse take to decrease the infant's pain?
a. Administer the injections while the infant is breastfeeding
b. Ask the parents to leave the room during the injections
c. Administer the injections into the deltoid muscle
d. Apply a warm pack to the injection site prior to administration
a. Administer the injections while the infant is breastfeeding
118
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. Assess the pin site for injection once every other day
b. Encourage flexion and extension of the neck
c. Reposition the client using a turning sheet
d. Tighten the screws on the hero device one quarter turn every 48 hours
c. Reposition the client using a turning sheet
119
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 keep the bicycle at least 3 feet from the curb while riding in the street
b. Your child should walk the bicycle through intersections
c. Your child should ride the bicycle against the flow of traffic
d. Your child seat should be 3 to 6 inches off the ground when seated on the bicycle
b. Your child should walk the bicycle through intersections
120
A nurse is assessing an adolescent client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect?
a. Night sweats
b. Unexplained weight gain
c. Decreased body temperature
d. Flushed skin
a. Night sweats
121
A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which of the following restraints should the nurse plan to use for this procedure?
a. Mummy
b. Jacket
c. Elbow
d. Mitten
a. Mummy
122
A nurse is assessing a child who has heart failure. Which of the following findings is a clinical manifestation associated with this diagnosis?
a. Tachypnea
b. Bradycardia
c. Increased appetite
d. Tremors
a. Tachypnea
123
A nurse is providing teaching to the parents of a child who has varicella about management of the disease. Which of the following instructions should the nurse include in the teaching?
a. Apply calamine lotion to vesicles on the child's skin
b. Dress a child in warm clothing to promote healing of vesicles
c. Avoid giving a child a bath while vesicles are present
d. Keep the child away from others until the skin is clear of scabs
a. Apply calamine lotion to vesicles on the child's skin
124
A charge nurse is teaching a group of nurses about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse?
a. A toddler has bruises on his knees
b. A mother is hesitant to comfort her six month old infant
c. An eight month old infant cries when he's parents leave the room
d. A toddler repeatedly refuses to let a nurse auscultate his lungs
d. A toddler repeatedly refuses to let a nurse auscultate his lungs
125
A nurse is caring for a child in the PACU following a tonsillectomy. Which of the following findings requires immediate intervention by the nurse?
a. axillary temperature 38 C (100 F)
b. Child report pain level of five on the FACES scale
c. Dark brown blood noted in emesis
d. Frequent swallowing
d. Frequent swallowing
126
A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first?
a. Encourage the client to attend a group therapy session
b. Assist the client if he is considering harming himself
c. Administer an anti-depressant
d. Assist the client in completing his ADLs
a. Encourage the client to attend a group therapy session
127
A nurse is teaching a group of male adolescents about testicular self- examination. Which of the following statements should the nurse include in the teaching?
a. You should perform the examination once every other month
b. If you feel a hard lump wait one month and retest yourself
c. Perform the examination following a warm shower
d. You should notify the provider if your testes are firm and egg shaped
c. Perform the examination following a warm shower
128
A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?
a. Place the child in a semi private room
b. Keep the staff visits with the child brief
c. Keep the television on in the child room for background noise
d. Vary daily routines when providing care for the child
b. Keep the staff visits with the child brief
129
A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?
a. Place the child in a protected environment for 48 hours
b. Restrict oral fluid to 500 mL per day
c. Administer the pertussis vaccine
d. Report the diagnosis to the public health department
a. Place the child in a protected environment for 48 hours
130
A nurse is planning to admit a preschooler from the PACU following removal of a Wilm's tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?
a. A child who has viral pneumonia
b. A child who has impetigo
c. A child who has a fractured left femur
d. A child who has cellulitis on the right radius
c. A child who has a fractured left femur
131
A nurse is planning care for an adolescent following repair of Meckel diverticulum. Which of the following actions should the nurse include in the plan of care?
a. Teach child about ostomy care
b. Administer total parenteral nutrition
c. Initiate long-term antibiotic therapy
d. Maintain an NG tube for decompression
d. Maintain an NG tube for decompression
132
A nurse is caring for a preschooler who has a brain tumor. Which of the following findings is the priority for the nurse to report to the provider?
a. puritus
b. nightmares
c. hyperactivity
d. diplopia
d. diplopia
133
A nurse in a community clinic is reviewing the laboratory results of four clients. The nurse should identify that which of the following sexually transmitted infections is nationally notifiable?
a. Genital herpes simplex virus
b. Bacterial vaginosis trichomoniasis
c. Gonorrhea
d. Human papilloma virus
c. Gonorrhea
134
A nurse is assessing a toddler who is 8 hours postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?
a. Bilateral cool extremities
b. Serum glucose 90 mg/dL
c. Blood pressure 102/58 mmHg
d. Weak pedal pulse distal to site
a. Bilateral cool extremities
135
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter. Which of the following actions should the nurse plan to take?
a. Gently rub the cream into the skin
b. Wash the site with alcohol prior to applying the cream
c. Apply the cream 1 hour before the procedure
d. Avoid removing the cream prior to the procedure
c. Apply the cream 1 hour before the procedure
136
A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12- month-old infant. Which of the following actions should the nurse plan to take?
a. Change the IV site every three days
b. Start the IV in the infant foot
c. Use a 24-gauge catheter to start the IV
d. Covered with opaque dressing
c. Use a 24-gauge catheter to start the IV
137
A nurse is teaching a parent about home interventions for a preschooler who is experiencing night terrors. Which of the following instructions should the nurse include in the teaching?
a. Allow your child to watch animated movies right before bed time
b. Wait until your child indicates that he is tired before putting him to bed
c. Avoid allowing your child to sleep in your bed
d. Wake your child up during the night terror
c. Avoid allowing your child to sleep in your bed
138
A nurse is providing teaching to the parents of a toddler who is to undergo a sweat chloride test. Which of the following statements should the nurse include?
a. The purpose of the test is determine if your child has Crohn's disease
b. The technician will come on a device to produce an electrical current during the test
c. During the test you placed in a room that is cold
d. Your child's sweat will be collected over 24 hours
d. Your child's sweat will be collected over 24 hours
139
A nurse is caring for a preschooler who is post-operative following a tonsillectomy. The child is now ready to resume oral intake which of the following dietary choices should the nurse offer the child?
a. Sugar-free cherry gelatin
b. Vanilla ice cream
c. Chocolate milk
d. Lime flavored ice pop
d. Lime flavored ice pop
140
A nurse is preparing a school-age child for an invasive procedure. Which of the following actions should the nurse plan to take?
a. Plan for 30-minute teaching session about the procedure
b. Use vague language to describe the procedure
c. Explain the procedure for the child when they are in the playroom
d. Demonstrate deep breathing and counting exercises
a. Plan for 30-minute teaching session about the procedure
141
A nurse is caring for a child who has hyponatremia. Which of the following findings should the nurse expect?
a. tetany
b. weight gain
c. elevated heart rate
d. excessive diaphoresis
d. excessive diaphoresis
142
A nurse is planning care for a school-age child who is admitted from the emergency department 12-hours-ago. Which of the following interventions should the nurse include to promote adequate sleep for the child?
a. Provide the child with video games prior to bedtime to reduce stress
b. Allow the child to adjust their bedtime to promote autonomy
c. Leave the lights on in child's room to promote safety
d. Follow the child's home sleep routine to reduce anxiety
d. Follow the child's home sleep routine to reduce anxiety
143
A nurse is caring for an infant who receives intermittent enteral feeding through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (SATA)
a. Offer the infant a pacifier during readings
b. Formula to 39 C (102 F) prior to administration
c. Check for residual volume by aspirating stomach contents
d. Instill the formula over a period of 30 to 45 minutes
a. Offer the infant a pacifier during readings
c. Check for residual volume by aspirating stomach contents
144
A nurse is providing teaching to the guardian of a school-age child who has sickle cell disease about management of the illness. Which of the following instructions should the nurse include?
a. Apply cold compress to painful areas
b. Wear a surgical mask to school
c. Encourage physical activity as tolerated
d. Offer fluids at bedtime
c. Encourage physical activity as tolerated
145
A nurse is discussing coping mechanism with a parent of a three-month-old infant which of the following therapeutic questions should the nurse ask the parent?
a. What do you do when your infant is fussy?
b. Are you willing to take a new parenting class?
d. Is it overwhelming when your infant is having a bad day?
d. Is it overwhelming when your infant is having a bad day?
146
A nurse is reviewing the medical record of a child with cystic fibrosis which of the following should the nurse report to the provider? Click the exhibit button for additional information about the client.
a. Heart rate
b. HbA1c
c. Oxygen saturation
d. WBC 48
c. Oxygen saturation
147
A nurse is assessing an infant who has intussusception. Which of the following findings should the nurse expect?
a. Sausage-shaped abdominal mass
b. Board like abdomen
c. Constipation
D. Increased urinary output
a. Sausage-shaped abdominal mass
148
A nurse is caring for a 14-year-old adolescent who has a cast on the right arm and swelling of their right hand. The nurse elevates the adolescents affected extremity. The nurse should identify that which of the following findings is an indication that the intervention has been effective?
a. The adolescent reports of the cast feeling tight
b. The adolescent hands feel cool to touch
c. The adolescent is able to move their fingers freely
d. The adolescent reports feeling tingling in their arms
c. The adolescent is able to move their fingers freely
149
A nurse is planning care for a school-age child who has a new diagnosis of Legg calve perthes disease. Which of the following interventions should the nurse include in the plan of care?
a. Instruct child to perform weight-bearing exercises
b. Explain to the child that the disease will last 3 to 6 months
c. Encourage the parents to keep the child home from school for one month
d. Administer ibuprofen to the child for discomfort
d. Administer ibuprofen to the child for discomfort
150
A nurse is caring for a two-year-old who has cystic fibrosis and is being discharge from the hospital. The nurse should ensure that which of the following pieces of equipment is available for the child's home?
a. Stem vaporizer
b. Suction machine
c. Continuous positive airway pressure machine
d. High frequency chest compression vest
d. High frequency chest compression vest
151
A nurse is providing teaching for the parent of a child who has measles. Which of the following information should the nurse include?
a. Bathe the child using tepid water
b. Remove loose crust from the lesions
c. Give the child aspirin for a fever
d. Withhold live vaccines for three months
a. Bathe the child using tepid water
152
A nurse is assessing a toddler who has cystic fibrosis. Which of the following findings should the nurse expect?
a. steatorrhea
b. rhinorrhea
c. weight gain
d. visible peristalsis
a. steatorrhea
