CORRECT ANSWERS
1. The nurse is caring for a 3-year old child who is 2 hours postop
from a cardiac catheterization via the right femoral artery. Which
assessment finding is an indication of arterial obstruction?
A. Blood pressure trend is downward and pulse is rapid and irregular.
B. Right foot is cool to the touch and appears pale and blanched.
C. Pulse distal to the femoral artery is weaker on the left foot than
right foot.
D.The pressure dressing at right femoral area is moist and oozing
blood.: B. Right foot is cool to the touch and appears pale and blanched.
2. Following a motor vehicle collision, a 3-year old girl has a spica
cast applied. Which toy is best for the nurse for this 3 year old child?
A. Duck that squeaks.
B. Fashion doll and clothes.
C. Set of cloth and hand puppets.
D. Hand held video game.: C. Set of cloth and hand puppets.
3. An infant with tetralogy of Fallot becomes acutely cyanotic and
hyperpneic. Which action should the nurse implement first?
A. Administer morphine sulphate.
,B. Start IV fluids.
C. Place the infant in a knee-chest position.
D. Provide 100% oxygen by face mask.: C. Place the infant in a knee-chest position.
4. A child admitted with diabetic ketoacidosis is demonstrating
Kussmaul respi- rations. The nurse determines that the increased
respiratory rate is a compen- satory mechanism for which acid base
alteration?
A. Metabolic alkalosis.
B. Respiratory acidosis.
C. Respiratory alkalosis.
D. Metabolic acidosis.: D. Metabolic acidosis.
5. 7 years old is admitted to the hospital with persistent
vomiting, and a naso- gastric tube attached to low intermittent
suction is applied. Which finding is most important for the nurse
to report to the healthcare provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mg/dL.
D. Serum pH of 7.45: C. Serum potassium of 3.0 mg/dL.
6. The nurse is evaluating diet teaching for a client who has
,nontropical sprue (celiac disease). Choosing which food indicates
that the teaching has been effective?
A. Creamed corn
B. Pancakes.
C. Rye crackers.
D. Cooked oatmeal.: A. Creamed corn
7. During a well-baby check, the nurse hides a block under the
baby's blanket, and the baby looks for the block. Which normal
growth and development milestone is the baby developing?
A. Separation anxiety.
B. Associative play.
C. Object prehension.
D. Object permanence.: D. Object permanence.
8. The nurse is measuring the frontal occipital circumference
(FOC) of a 3-months old
infant, and notes that the FOC has increased 5 inches since birth and
the child's head
appears large in relation to body size. Which action is most
important for the nurse to
take next?
A. Measure the infant's head-to-toe length.
B. Palpate the anterior fontanel for tension and bulging.
, C. Observe the infant for sunken eyes.
D. Plot the measurement on the infant's growth chart.: B. Palpate the anterior
fontanel for tension and bulging.
9. The nurse is preparing a 10 year old with a lacerated forehead for
suturing.
Both
parents and 12 year old sibling are at the child's bedside. Which
instruction best
supports family?
A. While waiting for the healthcare provider, only one visitor may
stay with the child.
B. All of you should leave while the healthcare provider sutures
the child's forehead.
C. It is best if the sibling goes to the waiting room until the
suturing is complet- ed.
D.Please decide who will stay when the healthcare provider begins
suturing.: D. Please decide who will stay when the healthcare provider begins suturing.
10. The nurse is planning for a 5-month old with
gastroesophageal reflux dis- ease whose
weight has decreased by 3 ounces since the last clinic visit one month
ago. To increase
caloric intake and decrease vomiting, what instructions should the