REAL EXAM QUESTIONS WITH
VERIFIED ANSWERS | ( NEW
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QUESTION 1
A nurse in the emergency department is caring for a 2-year-old child who was found
by his parents crying and holding a container of toilet bowl cleaner. The child's lips
are edematous and inflamed, and he is drooling. Which of the following is the priority
action by the nurse?
A. Remove the child's contaminated clothing.
B. Check the child's respiratory status.
C. Administer an antidote to the child.
D. Establish IV access for the child.
Correct Answer: B. Check the child's respiratory status.
Rationale: When applying the ABC priority setting framework, airway is always the
highest priority because the airway must be clear and open for oxygen exchange to
occur. Breathing is the second highest priority in the ABC priority setting framework
because adequate ventilatory effort is essential in order for oxygen exchange to occur.
QUESTION 2
A nurse is teaching a parent of a 12-month-old child about development during the
toddler years. Which of the following statements should the nurse include?
A. Your child should be referring to himself using the appropriate pronoun by 18
months of age.
B. A toddler's interest in looking at pictures occurs at 20 months of age.
C. A toddler should have daytime control of his bowel and bladder by 24 months of
age.
D. Your child should be able to scribble spontaneously using a crayon at the age of 15
,months.
Correct Answer: D. Your child should be able to scribble spontaneously using a
crayon at the age of 15 months.
Rationale: The nurse should teach the parent that at the age of 15 months, the toddler
should be able to scribble spontaneously, and at the age of 18 months, the toddler
should be able to make strokes imitatively.
QUESTION 3
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride
100 mL IV to infuse over 4 hours. The drop factor of the manual IV tubing is 60
gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
(Round the answer to the nearest whole number)
A. 20 gtt/min
B. 25 gtt/min
C. 30 gtt/min
D. 35 gtt/min
Correct Answer: B. 25 gtt/min
Rationale: 100 mL/4 hr × 60 gtt/mL × 1 hr/60 min = 6000/240 = 25 gtt/min.
QUESTION 4
A nurse is caring for an 18-year-old adolescent who is up to date on immunizations
and is planning to attend college. The nurse should inform the client that he should
receive which of the following immunizations prior to moving into a campus
dormitory?
A. Pneumococcal polysaccharide
B. Meningococcal polysaccharide
C. Rotavirus
D. Herpes zoster
,Correct Answer: B. Meningococcal polysaccharide
Rationale: The meningococcal polysaccharide immunization is used to prevent
infection by certain groups of meningococcal bacteria. Meningococcal infection can
cause life-threatening illnesses, such as meningococcal meningitis, which affects the
brain, and meningococcemia, which affects the blood. Both of these conditions can be
fatal. College freshmen, particularly those who live in dormitories, are at an increased
risk for meningococcal disease relative to other persons their age. Therefore, the
Centers for Disease Control and Prevention has issued a recommendation that all
incoming college students receive the meningococcal immunization.
QUESTION 5
A nurse is teaching the parent of an infant about food allergens. Which of the
following foods should the nurse include as being the most common food allergy in
children?
A. Cow's milk
B. Wheat bread
C. Corn syrup
D. Eggs
Correct Answer: A. Cow's milk
Rationale: According to evidence-based practice, the nurse should instruct the parent
that cow's milk is the most common food allergy in children. Some children are
sensitive to the protein, called casein, found in cow's milk. They have difficulty
metabolizing the casein and are, therefore, allergic to cow's milk.
QUESTION 6
A nurse is teaching the parent of a toddler about home safety. Which of the following
statements by the parent indicates an understanding of the teaching?
A. "I lock my medications in the medicine cabinet."
, B. "I keep my child's crib mattress at the highest level."
C. "I turn pot handles to the side of my stove while cooking."
D. "I will give my child syrup of ipecac if she swallows something poisonous."
Correct Answer: A. "I lock my medications in the medicine cabinet."
Rationale: Locking up medications and other potential poisons prevents access.
Toddlers have improved gross and fine motor skills that allow for further exploration
of the environment and possible access to hazardous substances.
QUESTION 7
A nurse is performing a physical assessment on a 6-month-old infant. Which of the
following reflexes should the nurse expect to find?
A. Stepping
B. Babinski
C. Extrusion
D. Moro
Correct Answer: B. Babinski
Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot
and causing the toes to fan and the big toe to dorsiflex, should be present until the age
of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.
QUESTION 8
A nurse is preparing to administer recommended immunizations to a 2-month-old
infant. Which of the following immunizations should the nurse plan to administer?
A. Human papillomavirus (HPV) and hepatitis A
B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis
(Tdap)
C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)