|Questions, Answers and Rationales|
1. Question: A nurse is teaching the mother of a child who has cystic fibrosis
and has a prescription for pancreatic enzymes three times per day. Which of
the following statements indicates that the mother understands the
teaching?
Answer: "My child will take the enzymes to help digest the fat in foods."
Rationale: Pancreatic enzymes in cystic fibrosis aid in digesting fats,
proteins, and carbohydrates due to pancreatic insufficiency. The correct
statement reflects understanding of the enzymes' role in fat digestion. Other
options are incorrect: enzymes don’t primarily improve metabolism, aren’t
taken 2 hours before meals, and are taken with meals, not after.
2. Question: A nurse is teaching a parent of a child with hemophilia how to
control a minor bleeding episode. Which of the following statements by the
parent indicates a need for further teaching?
Answer: "I will apply heat."
Rationale: Applying heat increases blood flow and can worsen bleeding in
hemophilia. The RICE method (Rest, Ice, Compression, Elevation) is
appropriate for minor bleeding episodes. Resting, compressing, and
elevating the affected part help control bleeding, but applying heat indicates
a misunderstanding, requiring further education.
3. Question: A nurse in an emergency department is caring for an infant who
has a 2-day history of vomiting and an elevated temperature. Which of the
following should the nurse recognize as the most reliable indicator of fluid
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, loss?
Answer: Body weight
Rationale: Body weight is the most accurate indicator of fluid loss in infants,
as even small changes reflect significant dehydration due to their high body
water content. Skin integrity, blood pressure, and respiratory rate are less
reliable, as they can vary due to other factors and are not as directly
correlated with fluid status.
4. Question: Which of the following children should the nurse identify as a
potential action of abuse?
Answer: A child whose parents answer questions for the child
Rationale: Parents answering for a child may indicate controlling behavior, a
potential sign of abuse, as it can suggest suppression of the child’s voice or
autonomy. Frequent visitors, frequent use of the call light, or obesity are not
direct indicators of abuse, though obesity may warrant nutritional
assessment.
5. Question: A nurse is assessing a 3-month-old. Which of the following
findings should he report to the provider?
Answer: Unable to raise head when in prone position
Rationale: A 3-month-old should lift their head when prone, indicating neck
muscle development. Inability to do so may suggest neurological or
developmental issues, warranting provider notification. The other findings
(inability to pick up objects, sit without support, or bring objects to mouth)
are normal for this age.
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,6. Question: A nurse is admitting a 6-month-old infant who has dehydration.
Which of the following amounts of urinary output should indicate to the
nurse that the treatment has confirmed the fluid imbalance?
Answer: 2 mL/kg/hr
Rationale: Normal urine output for infants is approximately 1-2 mL/kg/hr.
An output of 2 mL/kg/hr indicates adequate hydration, suggesting effective
treatment for dehydration. Outputs of 0.5 mL/kg/hr (too low), 7.5
mL/kg/hr, or 15 mL/kg/hr (excessive) do not confirm resolution of fluid
imbalance.
7. Question: A nurse is planning care for an infant who has spina bifida and is
to undergo surgical [procedure]. Which of the following interventions should
the nurse include in the plan of care?
Answer: Provide a latex-free environment
Rationale: Infants with spina bifida are at high risk for latex allergies due to
repeated medical exposures. A latex-free environment prevents allergic
reactions. Supine positioning may not be ideal pre-surgery, limiting visitors
is unnecessary, and contact precautions are not typically required unless
infection is present.
8. Question: A nurse is caring for a child who has just died. The parents ask to
be left alone so that they [can grieve]. The nurse should:
Answer: Grant their request
Rationale: Grieving parents should be given privacy to process their loss,
respecting their emotional needs. Discouraging this may hinder grief
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, processing, explaining they need to say goodbye now is insensitive, and
assessing their request is unnecessary unless safety concerns arise.
9. Question: A nurse is educating new parents on risk factors for sudden infant
death syndrome (SIDS). Which of the following statements by a parent would
indicate a need for additional teaching?
Answer: "Our baby will sleep in my bed because I am breastfeeding."
Rationale: Co-sleeping in the same bed increases SIDS risk due to potential
suffocation. Pacifier use, back sleeping, and removing blankets/toys from
the crib are SIDS prevention strategies. The co-sleeping statement indicates
a misunderstanding, requiring further education on safe sleep practices.
10. Question: A nurse is caring for an adolescent who has spina bifida and is
paralyzed from the waist down. Which of the following statements by the
client would indicate to the nurse a need for further teaching?
Answer: "I only need to catheterize myself twice every day."
Rationale: Adolescents with spina bifida typically require intermittent
catheterization every 4-6 hours (4-6 times daily) to prevent urinary
retention and infections. Catheterizing only twice daily is insufficient,
indicating a need for further teaching. The other statements reflect
appropriate self-care practices.
11. Question: A parent tells a nurse that her toddler drinks a quart of milk a
day and has a poor appetite for solid foods. The nurse should explain that
the toddler is at risk for which of the following disorders?
Answer: Iron deficiency anemia
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