Sample exam………

40 items Comprehensive NCLEX review answer key

1. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D)55 year-old Hispanic teacher

The correct answer is A: 45 year-old African American attorney The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

2. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy

The correct answer is A: Gastric lavage PRN Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure

The correct answer is B: thrombus formation Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea

C) Manage pain D) Prevent urinary tract infection

The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.

5. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year

The correct answer is D: Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height.

6. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check

The correct answer is A: go get a blood pressure check within the next 48 to 72 hours The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A) A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago

The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

8. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate

The correct answer is A: Should be taken in the morning Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

9. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status

The correct answer is D: Notify the health care provider of the child''s status These findings suggest a medical emergency and may be due to epiglottises. Any child with

an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss

The correct answer is C: Bed wetting In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by

the parents

11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus

The correct answer is B: Chlamydia Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

12. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C) An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day

The correct answer is C: Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for

digestion and is dangerous for the client with coronary artery disease.

14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon

The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints

The correct answer is B: Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation.

16. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability

The correct answer is A: Decrease in level of consciousness A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough

D) Meconium ileus

The correct answer is C: Moist, productive cough Option c is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas

and lungs. Respiratory failure is the most dangerous consequence of CF.

18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse

The correct answer is B: Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client''s best interest.

19. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination

The correct answer is D: No special orders are necessary for this examination No special preparation is necessary for this examination.

20. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without

problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk."

The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

21. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has buldging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula

The correct answer is B: A teenager who got singed a singed beard while camping This client is in the greatest

danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child."

The correct answer is C: "I understand the need to use those new skills." Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment.

23. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature

The correct answer is A: Verify correct placement of the tube Proper placement of the tube prevents aspiration.

24. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves

The correct answer is C: Tall peaked T waves A tall peaked T wave is a sign of hyperkalemia. The health care provider should be notified regarding discontinuing the medication.

25. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) All striated muscles B) The cerebellum C) The kidneys D) The leg bones

The correct answer is A: All striated muscles Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word and is “myo” which typically means muscle.

26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life D) Restore yin and yang

The correct answer is D: Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

27. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages

The correct answer is C: Force fluids and reassess blood pressure Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.

28. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function

The correct answer is B: Left heart function The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. The pressure readings are inferred from pressure measurements obtained on the right side of the circulation. Right- sided heart function is assessed through the evaluation of the central venous pressures (CVP).

29. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart

The correct answer is C: Establish an airway Establishing an airway is always the primary objective in a cardiopulmonary arrest.

30. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16

The correct answer is A: Blood pressure 94/60 Both medications decrease the heart rate. Metoprolol affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic B/P over 100) in order to safely administer both

medications.

31. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal

respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying

The correct answer is C: Inspiratory grunt Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant.

32. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency

The correct answer is D: Progressive placental insufficiency The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.

33. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today."

The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." The nurse would be concerned about all of these comments. However the most life threatening is option B. Clients who have had hip or knee surgery are at greatest risk for development of post operative pulmonary embolism. Sudden dyspnea and tachycardia are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Option C may indicate a urinary tract infection. And option D requires further investigation and is not life threatening.

34. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?

A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite

The correct answer is D: Decreased appetite Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias.

35. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year- old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2

The correct answer is C: Gravida 3 para 1 Gravida is the number of pregnancies and Parity is the number of

pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

36. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement

The correct answer is B: Improve the client''s nutrition status The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other answers are correct, but without proper nutrition, the other interventions would be of little help.

37. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder

The correct answer is D: Have the client empty bladder The first step in the process is to have the client void prior to administering the pre- operative medication. The other actions follow this initial step in this sequence: 4 3 1 2

38. Which of these statements best describes the characteristic of an effective reward-feedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable

The correct answer is A: Specific feedback is given as close to the event as possible Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if the standards are clearly understood.

39. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive

The correct answer is B: Lead to dehydration The client must take in adequate fluids before and during exercise periods.

40. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24

hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day.

The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to

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1. A child with leukemia is being discharged after beginning chemotherapy. Which of the following instructions will the nurse include when teaching the parents of this child?

a) provide a diet low in protein and high carbohydrates b) b) avoid fresh vegetables that are not cooked or peeled c) c) notify the doctor if the child's temperature exceeds 101 F (39C) d) d) increase the use of humidifiers throughout the house

Answer B fresh fruits and vegetables harbor microorganisms, which can cause infections in immune-compromised child. Fruits and vegetables should either be peeled or cooked. The physician should be notified of a temperature above 100F, a diet low in protein is not indicated, and humidifiers harbor fungi in the water containers.

2. A client with hemophilia has a very swollen knee after falling from bicycle riding. Which of the following is the first nursing action? a)initiate an IV site to begin administration of cryoprecipitate b) type and cross-match for possible transfusion c) monitor the client's vital signs for the first 5 minutes d) apply ice pack and compression dressings to the knee

Answer D rest, ice, compression, and elevation (RICE) are the immediate treatments to reduce the swelling and bleeding into the joint. These are the priority actions for bleeding into the joint of a client with hemophilia.

3. A client and her husband are positive for the sickle cell trait. The client asks the nurse about chances of her children having sickle cell disease. Which of the following is appropriate response by the nurse?

a)one of her children will have sickle cell disease b) only the male children will be affected c) each pregnancy carries a 25% chance of the child being affected d) if she had four children, one of them would have the disease

Answer C In autosomal recessive traits, both parents are carriers. There is a 25% chance with each pregnancy that a child will have the disease.

4. An 8 year old child has been diagnosed to have iron deficiency anemia. Which of the following activities is most appropriate for the child to decrease oxygen demands on the body? a)Dancing b) playing video games c) reading a book d) riding a bicycle

Answer C reading a book is restful activity and can keep the child from becoming bored. Choices a, b, and d require too much energy for a child with anemia and can increase oxygen demands on the body.

5. A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following would the nurse interpret as the priority?

a)applying lotions to the hands and feet b) offering foods the toddler likes c) placing the toddler in a quiet environment d) encouraging the parents to get some rest

Answer C One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. The child's irritability takes priority over peeling of the skin.

6.Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

a. Notify the physician immediately b. Administer antidiarrheal medications c. Monitor child ever 30 minutes d. Nothing, this is characteristic of Hirschsprung disease

Answer A. For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life- threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation.

7. A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?

a. Hirschsprung disease

b. Celiac disease

c. Intussusception

d. Abdominal wall defect

Answer A Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

8. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? a. Stool inspection

b. Pain pattern

c. Family history

d. Abdominal palpation

Answer C. Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

9. After teaching the parents of a preschooler who has undergone T and A (Tonsillectomy and Adenoidectomy) about appropriate foods to give the child after discharge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching? a)meatloaf and uncooked carrots b) pork and noodle casserole c) cream of chicken soup and orange sherbet d) hot dog and potato chips

Answer C for the first few days after a T and A (Tonsillectomy and Adenoidectomy), liquids and soft foods are best tolerated by the child while the throat is sore. Avoid hard and scratchy foods until throat is healed.

10. A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first? a)obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position

Answer D the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to- chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate hypoxia.

11. Which of the following would the nurse perform to help alleviate a child's joint pain associated with rheumatic fever?

a)maintaining the joints in an extended position b) applying gentle traction to the child's affected joints c)

supporting proper alignment with rolled pillows d) using a bed cradle to avoid the weight of bed lines on the joints

Answer D for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of the bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.

12. Which of the following health teachings regarding sickle cell crisis should be included by the nurse?

a)it results from altered metabolism and dehydration b) tissue hypoxia and vascular occlusion cause the primary problems c) increased bilirubin levels will cause hypertension d) there are decreased clotting factors with an increase in white blood cells

Answer B tissue hypoxia occurs as a result of the decreased oxygen-carrying capacity of the red blood cells. The sickled cells begin to clump together, which leads to vascular occlusion.

13. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

a. Susceptibility to respiratory infection

b. Bleeding tendencies

c. Frequent vomiting and diarrhea

d. Seizure disorder

Answer A Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

14. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?

a. Sucking ability b. Respiratory status

c. Locomotion

d. GI function

Answer A. Because of the defect, the child will be unable to from the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period,

Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip.

15. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?

a. Supine b. Prone c. In an infant seat d. On the side

Answer B. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as well as the prone position

16. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

a. Fluid volume deficit

b. Risk for aspiration

c. Altered nutrition: less than body requirements

d. Altered oral mucous membranes

Answer D GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses

17. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? a. Vomiting

b. Stools

c. Uterine

d. Weight

Answer A Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. No relationship exists between feedings and characteristics of stools and uterine. If feedings are ineffective, this should be noted before there is any change in the child’s weight.

18. An adolescent with a history of surgical repair for undescended testes comes to the clinic for a sport physical. Anticipatory guidance for the parents and adolescent would focus on which of the following as most important? a)the adolescent sterility b) the adolescent future plans c) technique for monthly testicular self- examinations d) need for a lot of psychosocial support

Answer C Because the incidence of testicular cancer is increased in adulthood among children who have undescended testes. It is extremely important to teach the adolescent how to perform the testicular self-examination monthly.

19. When developing the teaching plan for the parents of a 12 month old infant with hypospadias and chordee repair, which of the following would the nurse expect to include as most important? a)assisting the child to become familiar with his dressing so he will leave them alone b) encouraging the child to ambulate as soon as possible by using a favorite push toy c) forcing fluids to at least 250 ml/day by offering his favorite juices d) preventing the child from disrupting the catheter by using soft restraints

Answer D The most important consideration for a successful outcome of this surgery is maintenance of the catheters or stents. A 12 month old likes to explore his environment. Applying soft restraints will prevent the child from disrupting the catheter.

20. A school-aged client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with glomerulonephritis. Which of the following interventions would receive the highest priority? a)assessing vital signs every four hours b) monitoring intake and output every 12 hours c) obtaining daily weight measurements d) obtaining serum electrolyte levels daily

Answer C The child will glomerulonephritis experiences a problem with renal function that ultimately affects fluid balance. Because weight is the best indicator of fluid balance, obtaining daily weights would be the highest priority.

21. When assessing a 12 year old child with Wilm's tumor, the nurse should keep in mind that it most important to avoid which of the following?

a)measuring the child's chest circumference b) palpating the child's abdomen c) placing the child in an uprignt position d) measuring the child's occipitofrontal circumference

Answer B The abdomen of the child with Wilm's tumor should not be palpated because of the danger of disseminating tumor cells. The child with Wilm's tumor should always be handled gently and carefully

22. When positioning the neonate with an unrepaired myelomeningocele, which of the following positions would be most appropriate? a)supine the hip at 90 degree flexion b) right side-lying position with knees flexed c) prone with hips in abduction d) semi-fowler's position with chest and abdomen elevated

Answer C Before surgery, the infant is kept in the prone position to decrease tension on the sac. This allows for optimal positioning of the hips, knees, and feet because

orthopedic problems are common. The supine position is unacceptable because it causes pressure on the defect

23. A 4 year old with hydrocephalus is scheduled to have a ventroperitoneal shunt in the right side of the head. When developing the child's postoperative plan of care, the nurse would expect to place the preschooler in which of the following positions immediately after surgery? a)on the right side, with the foot of the bed elevated b) on the left side, with the head of the bed elevated c) prone with the head of the bed elevated d) supine, with the head of the bed flat

Answer D For at least the first 24 hours after insertion of a ventriculoperitoneal shunt, the child is positioned supine with the head of the bed flat to prevent too rapid decrease in CSF pressure. A rapid reduction in the size of the ventricles can cause subdural hematoma. Positioning on the operative site is to be avoided because it places pressure on the shunt valve, possibly blocking desired drainage of CSF. With continued increased ICP, the child would be positioned with the head of bed elevated to allow gravity to aid drainage.

24. After talking with the parents of a child with Down Syndrome, which of the following would the nurse identify as an appropriate goal of care of the child?

a)encouraging self-care skills in the child b) teaching the child something new each day c) encouraging more lenient behavior limits for the child d) achieving age-appropriate social skills

Answer A The goal in working with mentally challenged children is to train them to be as independent as possible, focusing on the developmental skills. The child may not be capable of learning something new every day but needs to repeat what has been taught previously. Rather than encouraging more lenient behavior limits, the parents need to be strict and consistent when setting limits for the child. Most children with Down syndrome are unable to achieve age-appropriate social skills due to their mental retardation. Rather, they taught socially appropriate behaviors.

25. When teaching an adolescent with a seizure disorder who is receiving Valproic acid (Depakene), which of the following would the nurse instruct the client to report the health care provider? a)three episodes of diarrhea b) loss of appetite c) jaundice d) sore throat

Answer C A toxic effect of valproic acid (Depakene) is liver toxicity, which may manifest with jaundice and abdominal pain. If jaundice occurs, the client needs to notify the health care provider as soon as possible.

26. A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which of the following play activities would be most appropriate at this time? a)reading the child a story b) painting with water colors c) pounding on a pegboard d) stacking a tower of blocks

Answer C The child is angry and needs a positive outlet for expression of feelings. An emotionally tense child with pent-up hostilities needs a physical activity that will release energy and frustration. Pounding on a pegboard offers the opportunity. Listening to a story does not allow child to express emotions. It also places the child in a passive role and does not allow the child to deal with feelings in a healthy and positive way. Activities such as paintings and stacking a tower of blocks require concentration and fine movements, which could add to frustration.

27. The parents of a child tell the nurse they feel guilty because their child almost drowned. Which of the following remarks by the nurse would be most appropriate? a)I can understand why you feel guilty, but these things happen b) tell me a bit more about your feelings of guilt c) you should not have taken your eyes off your child d) you really shouldn't fell guilty; you're lucky because your child will be alright

Answer B Guilt is a common parental response. The parents need to be allowed to express their feelings openly in a nonthreatening, nonjudgmental atmosphere.

28. The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following interventions would be most appropriate?

a)fitting the diaper under the straps b) leaving the harness off while the infant sleeps c) checking for the skin redness under straps every other day d) putting powder on the skin under the straps every day

Answer A The Pavlik harness is worn over a diaper. Knee socks are also worn to prevent the straps and foot and leg pieces from rubbing directly on the skin. For maximum results, the infant needs to wear the harness continuously. The skin should be inspected several times a day, not every other day, for signs of redness or irritation. Lotions and powders are to be avoided because they can cake and irritate the skin. (Hip dysplasia is a condition in which the head of the femur is improperly rested in the acetabulum, or hip socket of the pelvis. The characteristic manifestations are as follows: asymmetry of the gluteal and thigh folds; limited hip abduction in the affected hip; apparent shortening of the femur on the affected side (Galeazzi sign and Allis sign); weight bearing causes titling of the pelvis downward on the unaffected side (Trendelenberg sign); Ortolani click (in infant under 4 weeks of age).

29. When assessing the development of a 15 month old child with cerebral palsy, which of the following milestones

would the nurse expect a toddler of this age to have achieved?

a)walking up steps b) using a spoon c) copying a circle d) putting a block in cup

Answer D Delay in achieving developmental milestones is a characteristic of children with cerebral palsy. A 15 month old child can put a block in a cup. Walking up steps typically is accomplished at 18 to 24 months. A child usually is able to use a spoon at 18 months. The ability to copy a circle is achieved at approximately 3 to 4 years of age.

30. The nurse teaches the mother of a young child with Duchenne's muscular dystrophy about the disease and its management. Which of the following statements by the mother indicates successful teaching? a)my son will probably be unable to walk independently by the time he is 9 to 11 years old b) muscle relaxants are effective for some children; I hope they can help my son c) when my son is a little bit older, he can have surgery to improve his ability to walk d) I need to help my son be as active as possible to prevent progression of the disease

Answer A Muscular dystrophy is an X-linked recessive disorder. The gene is transmitted through female carriers to affected sons 50% of the time. Daughters have a 50% chance of being carriers. It is a progressive disease. Children who are affected by this disease usually are unable to walk independently by age 9-11 years. There is no effective treatment for the disease. A characteristic manifestation is Gower's sign -- the child walks the hands up the legs in an attempt to rise from sitting to standing position.

31. Which of the following foods would the nurse encourage the mother to offer to her child with iron-deficiency anemia?

a)rice cereal, whole milk, and yellow vegetables b) potato, peas, and chicken c) macaroni, cheese and ham d) pudding, green vegetables and rice

Answer B potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice, by itself also is not a good source of iron.

32. Because of the risks associated with administration of factor VIII concentrate, the nurse would report which of the following? a)yellowing of the skin b) constipation c) abdominal distention d) puffiness around the eye

Answer A Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present.

33. When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove

formula and drainage. Which of the following solutions would the nurse use?

a)mouthwash b) providone - iodine (betadine) solution c) a mild antiseptic solution d) half-strength hydrogen peroxide

Answer D half-strength hydrogen peroxide is recommended for cleansing the suture line after cleft lip repair. The bubbling action of the hydrogen peroxide is effective for removing debris. Normal saline also may be used. Mouthwashes frequently contain alcohol which can be irritating. Povidone-iodine solution is not used because iodine contained in the solution can be absorbed through the skin, leading to toxicity. A mild antiseptic solution has some antibacterial properties but is ineffective in removing suture-line debris.

34. Which of the following nursing diagnosis would the nurse identify as a priority for the infant with tracheoesophageal fistula (TEF)? a)impaired parenting related to newborn's illness b) risk of injury related to increased potential for aspiration c) ineffective nutrition: less than body requirements, related to poor sucking ability d) ineffective breathing pattern related to a weak diaphragm

Answer B because the blind pouch associated with TEF fills quickly with fluids, the child is at risk for aspiration. Children with TEF usually develop aspiration pneumonia.

35. When the infant returns to the unit after imperforate anus repair, the nurse places the infant in which of the following position? a)on the abdomen, with legs pulled up under the body b) on the back, with legs extended straight out c) lying on the side with hips elevated d) lying on the back in a position of comfort

Answer C after surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at 90-degree angle or on either side with the hips elevated to prevent pressure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate with the legs extended straight out

36. A child presents to the emergency room with the history of ingesting a large amount of acetaminophen. For which of the following would the nurse assess?

a)hypertension b) frequent urination c) Right upper quadrant pain d) headache

Answer C after ingesting a large amount of acetaminohen, the child would complain of right upper quadrant pain due to hepatic damage from glutathione combining with the metabolite of acetaminophen being broken down.

37. Which of the following statements by the mother of an 18 month old would indicate to the nurse that the child needs laboratory testing for lead levels? a)my child does

not always wash after playing outside b) my child drinks 2 cups of milk everyday c) my child has more temper tantrums than other kids d) my child is smaller than other kids of the same age

Answer A eating with dirty hands, especially after playing outside, can lead to lead poisoning because lead is often present in soil surrounding homes. When blood levels of lead reaches 15-19 mg/dL.., an investigation of the child's environment will be initiated. Oral chelation therapy is started when blood lead levels reached 45 mg/dL. When they reach 70 mg/dL, the child usually is hospitalized for intravenous chelation therapy.

38. Which of the following statements is LEAST accurate concerning urinary tract infections (UTI) in children?

A)A negative urinalysis rules out UTI in children < 2 years of age. B)B) Children with multiple UTIs should be evaluated for abuse. C) Infants younger than 3 months of age with a UTI should be admitted for intravenous antibiotics. D) Neonatal boys are more prone to UTIs than girls. E) Well appearing children > 3 months old with pyelonephritis may be treated as outpatients.

Answer A

A negative urinalysis rules out UTI in children < 2 years of age. In children younger than 2-years-old, a negative urinalysis does not rule out a urinary tract infection. Up to 50% of children with UTIs can have a false negative urinalysis. Nitrite and leukocyte esterase presence in urine dipstick have the highest combined sensitivity for UTI. In addition, if both are positive, the false positive rate is less than 4%. Most consider young girls to be at the highest risk for UTI. This is in fact true except for the neonatal period, when neonatal boys actually have a higher risk than girls. Children with UTIs are managed differently based on the age of the child. The very young are treated conservatively, and those under 3 months of age are generally admitted to the hospital for IV antibiotics. Pyelonephritis used to be commonly managed as an inpatient, but in well appearing children, this infection can be treated as an outpatient with oral antibiotics.

39. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions?

a. Sims’. b. Side-lying. c. Supine. d. Prone.

Answer B.

Side-lying — CORRECT: most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction. Supine — increased risk for aspiration, would not facilitate drainage of oral secretions Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing Sims’ — on side with top knee

flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination

40. Which of the following statements indicate that the adolescent is having an early sign of anorexia nervosa?

a)I have my menses every month b) I go out to eat with my friends c) I run three times a day for a total of 5 hours per day d) I try to maintain my weight around 115 lbs. for my height of 5 feet

Answer C excessive exercise, consumption of very small amounts of food and food rituals, amenorrhea, and excessive weight loss or weight is below normal, lanugo, dry skin, bradycardia, are all signs of anorexia nervosa.

41. Which of the following signs and symptoms would observe in a child diagnosed of laryngotracheobronchitis?

a)predominant stridor on inspiration b) predominant expiratory wheeze c) high fever d) slow respiratory rate

Answer A Because croup cause upper airway obstruction, inspiratory stridor is predominant symptom

42. A child discharged with slow cerebrospinal fluid (CSF) leak 3 days after a head injury was sustained. What will the nurse include in the discharge plans? a)avoid use of nonsteroidal anti-inflammatory drugs b) turn from side to side only c) maintain complete bed rest d) gradually increase diet to clear liquids

Answer C most CSF leaks resolve spontaneously. The child should be maintained on bed rest until CSF leak stops. NSAID's may be used. The child may assume position of comfort. There are no dietary restrictions.

43. What would cause the closure of the Foramen ovale after the baby had been delivered?

a. Decreased blood flow b. Shifting of pressures from right side to the left side of the heart c. Increased PO2 d. Increased in oxygen saturation

Answer B During feto-placental circulation, the pressure in the heart is much higher in the right side, but once breathing/crying is established, the pressure will shift from the R to the L side, and will facilitate the closure of Foramen Ovale. (Note: that is why you should position the NB in R side lying position to increase pressure in the L side of the heart.)

44. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to assess which of the following?

a. Symmetrical gluteal folds b. Trendelemburg sign c. Ortolani’s sign d. Characteristic limp

Answer C Ortolani’s sign is the abnormal clicking sound when the hips are abducted. The sound is produced when the femoral head enters the acetabulum. Letter A is wrong

because its should be ―asymmetrical gluteal fold‖. Letter B and C are not applicable for newborns because they are seen in older children.

45. A newborn’s failure to pass meconium within 24 hours after birth may indicate which of the following?

a.Aganglionic Mega colon b. Celiac disease c. Intussusception d. Abdominal wall defect

Answer A Failure to pass meconium of Newborn during the first 24 hours of life may indicate Hirschsprung disease or Congenital Aganglionic Megacolon, an anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. B, C, and D are not associated in the failure to pass meconium of the newborn.

46. A 13-year-old girl appears at your office at 5:05 PM for a 3:30 PM appointment scheduled for the day before. Her mother tells you that the girl has been limping for a couple of weeks and has much knee pain. She has been afebrile, does not recall being hit in the knee or leg, and has not had any illnesses recently. She has difficulty "moving her leg inward." Given the late hour and that the workup will be done in the emergency department, you impress the pediatric emergency department staff by telling them that the most likely diagnosis is one of the following:

A. She twisted the leg trying to be on time for the appointment yesterday B. Septic arthritis of the hip C. Septic arthritis of the knee D. Aseptic necrosis of the hip E. Slipped capital femoral epiphysis

Answer E Slipped capital femoral epiphysis typically presents in girls aged 11 to 13 years and boys aged 13 to 15 years who are obese. It is most common in blacks. Although a slipped capital femoral epiphysis can produce pain localized to the groin area, it often presents as knee pain, especially on the board examination. Internal rotation is difficult. If you were to suggest an x-ray, anteroposterior and frog lateral x-rays of the pelvis would be the way to go.

47. You are in your office late one cold winter evening, seeing a pair of siblings who have a cold and cough. The mother and paternal grandmother are there. The grandmother notes that the best way to prevent the spread of colds is by wearing a wool hat at all times. What should you say? A.Agree and pull out a cartoon with the trademarked hats promoting your practice B. Wearing a face mask and eye shields is the best method C. Limiting exposure to other children to once weekly would help D.Washing hands and all toys frequently would be fine E. Isolating all children with colds is the best method

Answer D Hand washing and cleaning toys that are shared by children are the most effective means of preventing the spread of colds and upper respiratory tract infections during winter. If wearing a hat during cold weather prevented the spread of colds, then children in warm climates, would never get sick.

48. A 12-year-old boy who is at the 90th percentile for weight complains of slight pain in the right thigh and knee for about a month. His complains are made worse by physical activity and he has a mild limp. He has no history of recent infections or trauma. Physical examination reveals a slight decrease in internal rotation of the right hip. There is mild right-sided metaphyseal osteopenia on radiograph. Of the following, which would be the MOST likely diagnosis in this boy? A) Transient synovitis B) Septic arthritis C) Osteomyelitis D) Slipped capital femoral epiphysis E) Legg-Calve-Perthes disease

ANSWER D

Slipped Capital Femoral Epiphysis occurs as the result of acute or repetitive microtrauma to a probable abnormal femoral growth plate. It is unilateral in 40%-80% of cases and occurs during or just prior to the adolescent growth spurt (age 10 to 13 years). It is more commonly seen in boys and in very obese and/or very tall adolescents. Onset prior to age 10 years may indicate an underlying endocrine problem such as hypothyroidism. The clinical presentation is a limp with pain related to the hip joint. There may be some shortening of the involved limb, and internal rotation is limited. Biplanar radiographs or computed tomographic scans will establish the diagnosis. Mild demineralization of the metaphysis on the involved side is often associated.

49. A male infant weighing 3 kg is born via spontaneous vaginal delivery at 37 weeks’ gestation. His Apgar score is 6/9 at 1 and 5 minutes. The patient is in no apparent distress. Physical examination reveals no anus. What is the most appropriate initial step in this patient’s management? (A)Colostomy (B) Continued observation for 24 hours (C) Intubation and mechanical ventilation (D) Magnetic resonance imaging (MRI) of the abdomen and pelvis (E) Posterior sagittal anorectoplasty

Answer B Continued observation for 24 hours. The patient should be observed for delayed passage of meconium, as this can be normal up to 48 hours of life. If delayed beyond this period, meconium ileus, meconium plug, imperforate anus, or Hirschsprung’s disease should be considered. Evaluation of imperforate anus should include inspection for drainage of meconium through a fistula to the perineum or the urinary tract because this significantly alters treatment.1 Specifically, fistulae occur with low termination of the colon/rectum, which can be managed definitively with anorectoplasty. Absence of a fistula significantly increases the likelihood of a ―high defect‖ imperforate anus, which can be managed with colostomy and subsequent contrast imaging of the distal colon/rectum, followed by definitive repair at a few months of age. Some surgeons obtain a cross-table lateral abdominal radiograph (not MRI) to determine where the terminal colon/rectum lies in relation to the perineum, but this approach is unnecessary and is not widely practiced. Ultrasonography and radiography are required to rule out VACTERL association, but there is no need for MRI. Intubation and mechanical ventilation are not indicated in this case.

50. A previously healthy 5-year-old girl presents to the ED with her parents with a temperature of 100.8°F (38.2°C) and a 2-day history of decreased appetite and persistent vague abdominal pain withtenderness in the mid-abdomen and right lower quadrant. Her parents report that she has had no appetite and felt nauseous but has not vomited. Laboratory results are unremarkable except for a white blood cell count of 16,000 cells/mL (normal, 4500– 11,000 cells/mL). Ultrasound of the abdomen and pelvis is inconclusive, and the patient is admitted to the hospital for observation. Eighteen hours into her hospital stay, she passes copious amounts of bloody stool. She remains hemodynamically stable with normal vital signs and no change in her abdominal pain. What is this patient’s most likely diagnosis? (A)Appendicitis

(B) Colonic arteriovenous malformation

(C) Colonic diverticulitis

(D) Gastric stress ulcer

(E) Meckel’s diverticulitis

Answer (E) Meckel’s diverticulitis. Hemorrhage is the most common complication of Meckel’s diverticulitis in children; therefore, this condition should be considered in any child with abdominal pain of unclear etiology associated with GI hemorrhage. Intestinal obstruction is another possible diagnosis but is more common in adults. The diagnosis of Meckel’s diverticulitis can be confirmed by 99mTc-pertechnetate scan, which detects heterotopic gastric mucosa or pancreatic tissue within the diverticulum. Meckel’s diverticula are usually completely asymptomatic, but resection is necessary when complications develop. Colonic arteriovenous malformations can cause GI hemorrhage in children but are much less common than Meckel’s diverticula. Appendicitis is common in children but very rarely causes hemorrhage. Colonic diverticulitis and gastric stress ulcers are exceedingly rare in children and are unlikely in this case.

51. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4 year-old boy who is non- verbal. This child does not have on any identification. What should the nurse do? A: Contact the provider B: Ask the child to write their name on paper. C: Ask a co-worker about the identification of the child. D: Ask the father who is in the room the child’s name.

Answer D

In this case you are able to determine the name of the child by the father’s statement. You should not withhold the medication from the child following identification.

52. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A: Slow pulse rate B: Weight gain C: Decreased systolic pressure D: Irregular WBC lab values

Answer B

Weight gain is associated with CHF and congenital heart deficits.

53. A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome? A: Simian crease

B: Brachycephaly

C: Oily skin

D: Hypotonicity

Answer C

The skin would be dry and not oily.

54. Who among the following pediatric client should be assessed first by the nurse?

a)the child with 2 episodes of soft stools during the shift b) the child who had cough for the past three days, with clear nasal discharge and is irritable c) the child with 2 episodes of inconsolable crying while the knees are drawn over the abdomen and plays between the episodes d) the child with skin rashes on his face and trunk

Answer C - this indicates appendicitis. The pattern of abdominal pain in appendicitis is as follows: pain occurs for 2 to 3 hours, pain is relieved in 2 to 3 hours, the n pain recurs and persists. During the time that pain subsides, it is when rupture of appendicitis may occur unnoticed.

55. The nurse is caring for several infants who are 2-day old. Who among these infants should be given highest priority by the nurse?

a) a bottlefed infant who takes 1-ounce of milk every 3 to 5 hours b) a breastfed infant who lost 0.5 ounce of his weight c) a bottlefed infant who takes 2 to 3 ounces of milk every 2 to 4 hours d) a breastfed infant who feeds every 2 to 4 hours

Answer A - the client experiences poor feeding (1 ounce = 30 ml) which indicates specific problems. The infant normally looses weight during the first week of life and he/she usually gains weight on the second week.

56. Which of the following can indicate left- sided heart failure in an infant?

A: fever

B: low appetite

C: increased respiratory rate

D: crying

. Answer C. Shortness of breath and perspiration during feeding can also indicate left-sided heart failure.

57. Which of the following is NOT part of the triad of cystic fibrosis?

A: pancreatic enzyme deficiency

B: fever

C: high concentration of sweat electrolytes

D: COPD

Answer B. The triad of cystic fibrosis is COPD, pancreatic enzyme deficiency, and a high concentration of sweat electrolytes.

58. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?

a. Lowered resistance from malnutrition

b. Ineffective functioning of the Eustachian tubes

c. Plugging of the Eustachian tubes with food particles

d. Associated congenital defects of the middle ear.

Answer B Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well- nourished and maintain adequate nutrition through the use of proper feeding techniques. Food particles do not pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities.

59. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

a. Susceptibility to respiratory infection

b. Bleeding tendencies

c. Frequent vomiting and diarrhea

d. Seizure disorder

Answer A. Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

60. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

a. Notify the physician immediately

b. Administer antidiarrheal medications

c. Monitor child ever 30 minutes

d. Nothing, this is characteristic of Hirschsprung disease

Answer A. For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life- threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation.

61. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following? a. Regurgitation

b. Steatorrhea

c. Projectile vomiting

d. ―Currant jelly‖ stools

Answer C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. ―Currant jelly‖ stools are characteristic of intussusception.

62. Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night?

a. ―Allow him to fall asleep in your room, then move him to his own bed.‖

b. ―Tell him that you will lock him in his room if he gets out of bed one more time.‖

c. ―Encourage active play at bedtime to tire him out so he will fall asleep faster.‖

d. ―Read him a story and allow him to play quietly in his bed until he falls asleep.‖

Answer D. Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

63. The nurse is caring for a 4-year old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services? a. Patching one of the eyes to strengthen the muscles b. Providing suckers and pinwheels to strengthen tongue movement c. Providing musical tapes

to [provide auditory training d. Encouraging play with a video game to improve muscle coordination

Answer B The nurse can help ready the child with cerebral palsy for speech therapy by providing activities that help the child develop tongue control.

64. The mother of a 3 year old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:

a. Feed the baby only when he is hungry b. Burp the baby after feeding is completed c. Place the baby in supine with head elevated d. Burp the baby frequently throughout the feeding

Answer D Burping the baby throughout the feeding will help prevent gastric distention that contributes to esophageal reflux

65. The mother of a child with hemophilia asks the nurse which over the counter medication is suitable for her child’s discomfort.

a. Advil (Ibuprofen) b. Tylenol (Acetaminophen) c. Aspirin (acetylsalicytic acid) d. Naproxen (Naprosyn)

Answer B The nurse should recommend acetaminophen for the child’s joint discomfort because it will have no effect on the bleeding time.

66. The nurse is assessing an infant with hirschspung’s disease. The nurse can expect the infant to: a. Weight less than expected for height and age b. Have infrequent bowel movements c. Exhibit clubbing of fingers and toes d. Have hyperactive deep tendon reflexes

Answer B The infant with hirschsprung’s disease will have infrequent bowel movements.

66. The nurse is to administer Digoxin Elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100. the nurse should:

a. Record the heart rate and call the physician b. Record the heart rate and administer the medication c. Administer the medication and recheck the heart rate in 30 minutes d. Hold the medication and recheck the heart rate in 30 minutes.

Answer B The infant’s apical heart rate is within the accepted range for administering the medication.

67. An 18-month old is scheduled for a cleft palate repair. The usual type of restraints for the child with cleft palate repair are:

a. Elbow restraints b. Full arm restraints c. Wrist restraints d. Mummy restraints

Answer A The least restrictive restraint for infant with a cleft lip and cleft palate repair is elbow restraint.

68. An infant with tetralogy of fallot is discharged with a prescription of lanoxin elixir. The nurse should instruct the mother to: a. Administer the medication using a nipple b. Administer the medication using a calibrated dropper in the bottle c. Administer the medication using a plastic baby spoon d. Administer the medication in the baby bottle with 1oz of water

Answer B The medication should be administered using a calibrated dropper that comes with the medication. Other choices are not necessary because a part or all of the medication could be lost during administration.

69. The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

a.Holding the infant b.Offering a pacifier c.Providing a mobile d.Offering sterile water

Answer B The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted.

70. A 5-year old with congestive heart failure has been receiving Digoxin (Lanoxin). Which finding indicated that the medication is having a desired effect.

a.Increased urinary output b.Stabilized weight c.Improved appetite d.Increased pedal edema

Answer A Lanoxin slows and strenghtens the contractions of the heart. An increase in urinary output shows that the medication is having a desired effect.

71. A 9-year old is admitted with suspected rheumatic fever. Which finding is suggested of polymigratory arthritis?

a. Irregular movements of the extremities and facial grimacing b. Painless swelling over the extensor surfaces of the joints c. Faint areas of red demarcation ovet the back and abdomen d. Swelling, inflammation and effusion of the joints

Answer D The child with poly migratory arthritis will exhibit a painful and swollen joints.

72. A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to:

a. Prevent insensible water loss b. Provide a moist environment with oxygen at 30% c. Prevent dehydration and reduce fever d. Liquefy secretions and relieve laryngeal spasm

Answer D The primary reason for placing the child with croup under a mist tent is to liquefy secretions and relieve laryngeal spasm.

73. The nurse is caring for an 8-year old following a routine tonsillectomy. Which finding should be reported immediately?

a. Reluctance to swallow b. Drooling of blood-tinged saliva c. An axillary temperature of 99F d. Respiratory stridor

Answer D Respiratory stridor is a symptom of partail airway obstruction.choice A,B and C are expected with a tonsillectomy.

74. A 2-year old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

a. ―currant jelly‖ stools b. Projectile vomiting c. ―ribbonlike‖ stools d. Palpable mass over the flank

Answer A A child with intussusception has stools that contain blood and mucus, which are described as ―currant jelly‖ stools.

75. A 4-year old is admitted with acute leukemia. It will be most important to monitor the child for:

a. Abdominal pain and anorexia b. Fatigue and bruising c. Bleeding and pallor d. Petichiae and mucosal ulcers

Answer C A child with leukemia has low platelet cout which contributes to spontaneous bleeding.

76. A 6-month old client with ventral septal defect is receiving digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

a. Blood pressure of 126/80 b. Blood glucose of 110mg/dl c. Heart rate of 60 bpm d. Respiratory rate of 30 cpm

Answer C A heart rate of 60 in the baby should be reported immediately. The dise should be held if the heart rate is blow 100bpm. The blood glucose, blood pressure and respirations are within the normal limits.

77. A priority nursing diagnosis for a child being admitted from a surgery following a tonsillectomy is:

a. Altered nutrition b. Impaired communication c. Risk for aspiration d. Altered urinary elimination

Answer C The first priority should be on airway, breathing and circulation.

78. An infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which medication. a. Digoxin b. Epinephrine c. Aminophyline d. Atropine

Answer A The infant with tetralogy of fallot has four heart defects. He will be treated with Digoxin to slow and strengthen the heart. Epinephrine, aminophyline and atropine will speed the heart rate and will not used in this client.

79. In a child with suspected coarctation of the aorta, the nurse would expect to find

A)Strong pedal pulses B) Diminishing cartoid pulses C) Normal femoral pulses D) Bounding pulses in the arms

Answer D: Bounding pulses in the arms Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)

80. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client? A)Hyperextension of the neck with passive shoulder flexion B) Flexion of the hip and knees with passive flexion of the neck C) Flexion of the legs with rebound tenderness D) Hyperflexion of the neck with rebound flexion of the legs

Answer is B: Flexion of the hip and knees with passive flexion of the neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of the neck; a positive Kernig’s sign—inability to extend the knee to more than 135 degrees, without pain behind the knee, while the hip is flexed usually establishes the diagnosis of meningitis

81. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A)"There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend."

Answer C: "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." All of the options will be concerns with cystic fibrosis, however the respiratory threats are the major concern in these clients. Other information of interest is that cystic fibrosis is an autosomal recessive disease. There is a 25% chance that each of these parent''s pregnancies will result in a child with systic fibrosis.

82. During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?

A) My child has lost 3 pounds in the last month. B) Urinary output seemed to be less over the past 2 days. C) All the pants have become tight around the waist. D) The child prefers some salty foods more than others.

Answer C: Clothing has become tight around the waist Parents often recognize the increasing abdominal girth first. This is an early sign of Wilm''s tumor, a malignant tumor of the kidney.

83. A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A)Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently

Answer C Continue with the present formula The recommended age for switching from formula to whole milk is 12 months. Switching to cow''s milk before the age of 1 can predispose an infant to allergies and lactose intolerance.

84. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

A)Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure

Answer D Note patterns of increased blood pressure Hypertension is a key assessment in the course of the disease.

85. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child's reaction to impending surgery. Which nursing intervention would be best to prepare the child? A) Introduce the child to all staff the day before surgery B) Explain the surgery 1 week prior to the procedure C) Arrange a tour of the operating and recovery rooms D) Encourage the child to bring a favorite toy to the hospital

Answer B Explain the surgery 1 week prior to the procedure A 5 year-old can understand the surgery, and should be prepared well before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.

86. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings?

A)Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation

Answer B Tissue hypoxia When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly attributable to tissue hypoxia, a decrease in the oxygen carrying capacity of the blood.

87. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

A)Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top

Answer A Measure head circumference In meningitis, assessment of neurological signs should be done frequently. Head circumference is measured because subdural effusions and obstructive hydrocephalus can develop as a complication of meningitis. The client will have already been on airborne precautions and crib top applied to bed on admission to the unit.

88. An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of: A)Septicemia B) Dehydration C) Hypokalemia D) Hypercalcemia

Answer B Dehydration Clinical findings dehydration include lethargy, irritability, dry skin, and increased pulse.

89. A nurse aide is taking care of a 2 year- old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements? A) "Touching the abdomen could cause cancer cells to spread." B) "Examining the area would cause difficulty to the child." C) "Pushing on the stomach might lead to the spread of infection." D) "Placing any pressure on the abdomen may cause an abnormal experience."

Answer A "Touching the abdomen could cause cancer cells to spread." Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The other options are similar but not the most specific.

90. A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?

A: Administer Loritab to the patient for pain relief. B: Place the patient in right sidelying position for pressure relief. C: Start a Central Line. D: Provide pain reduction techniques without administering medication.

Answer D Do not administer pain medication or start a central line without MD orders.

91. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions?

a. Sims’. b. Side-lying. c. Supine. d. Prone.

Answer B.

Side-lying — CORRECT: most effective to facilitate drainage of secretions from the mouth and pharynx; reduces possibility of airway obstruction. Supine — increased risk for aspiration, would not facilitate drainage of oral secretions Prone — risk for airway obstruction and aspiration, unable to observe the child for signs of bleeding such as increased swallowing Sims’ — on side with top knee flexed and thigh drawn up to chest and lower knee less sharply flexed: used for vaginal or rectal examination

92. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

a. Fluid volume deficit

b. Risk for aspiration

c. Altered nutrition: less than body requirements

d. Altered oral mucous membranes

Answer D

GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses

93. Which of the following foods would the nurse encourage the mother to offer to her child with iron-deficiency anemia?

a)rice cereal, whole milk, and yellow vegetables b) potato, peas, and chicken c) macaroni, cheese and ham d) pudding, green vegetables and rice

Answer B potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice, by itself also is not a good source of iron.

94. Which of the following would the nurse perform to help alleviate a child's joint pain associated with rheumatic fever?

a)maintaining the joints in an extended position b) applying gentle traction to the child's affected joints c) supporting proper alignment with rolled pillows d) using a bed cradle to avoid the weight of bed lines on the joints

Answer D for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of the bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.

95. A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?

a. Hirschsprung disease

b. Celiac disease

c. Intussusception

d. Abdominal wall defect

Answer A Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

96. Which of the following health teachings regarding sickle cell crisis should be included by the nurse?

a)it results from altered metabolism and dehydration b) tissue hypoxia and vascular occlusion cause the primary problems c) increased bilirubin levels will cause hypertension d) there are decreased clotting factors with an increase in white blood cells

Answer B tissue hypoxia occurs as a result of the decreased oxygen-carrying capacity of the red blood cells. The sickled cells begin to clump together, which leads to vascular occlusion.

97. When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove formula and drainage. Which of the following solutions would the nurse use?

a)mouthwash b) providone - iodine (betadine) solution c) a mild antiseptic solution d) half-strength hydrogen peroxide

Answer D half-strength hydrogen peroxide is recommended for cleansing the suture line after cleft lip repair. The bubbling action of the hydrogen peroxide is effective for removing debris. Normal saline also may be used. Mouthwashes frequently contain alcohol which can be irritating. Povidone-iodine solution is not used because iodine contained in the solution can be absorbed through the skin, leading to toxicity. A mild antiseptic solution has some antibacterial properties but is ineffective in removing suture-line debris.

98. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? A: Slow pulse rate B: Weight gain C: Decreased systolic pressure D: Irregular WBC lab values

Answer B

Weight gain is associated with CHF and congenital heart deficits.

99. In a child with suspected coarctation of the aorta, the nurse would expect to find

A)Strong pedal pulses B) Diminishing cartoid pulses C) Normal femoral pulses D) Bounding pulses in the arms

Answer D: Bounding pulses in the arms Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes increased flow to the upper extremities (increased pressure and pulses)

100. Which of the following signs and symptoms would observe in a child diagnosed of laryngotracheobronchitis?

a)predominant stridor on inspiration b) predominant expiratory wheeze c) high fever d) slow respiratory rate

Answer A Because croup cause upper airway obstruction, inspiratory stridor is predominant symptom

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