|Very Comprehensive | Latest 2024_2025 |
1. Question: A nurse is providing teaching to the parents of a school-aged child
who has ADHD. Which of the following instructions should the nurse include?
Answer: a. Place the child’s daily activities on an organizational chart
Rationale: Children with ADHD benefit from structured routines to manage
impulsivity and inattention. An organizational chart visually outlines daily tasks,
promoting consistency and reducing overwhelm. This tool helps the child
anticipate activities, improving focus and time management. Other options, like
rewarding positive behavior, are useful but less specific to daily structure. The
chart directly addresses the need for predictability, a key strategy in ADHD
management, as it aligns with evidence-based behavioral interventions for
school-aged children.
2. Question: A nurse is completing an admission assessment on an adolescent
child who is a vegetarian. He eats milk products but does not like beans. Which
of the following items should the nurse suggest the client order for lunch to
provide nutrients most likely to be lacking in his diet?
Answer: a. Peanut butter and jelly sandwich
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,Rationale: A vegetarian adolescent who consumes milk but avoids beans may lack
protein and iron. A peanut butter and jelly sandwich provides plant-based protein
and some iron, addressing these deficiencies. Milk products supply calcium and
vitamin D, but protein sources are limited without beans. This choice supports
nutritional balance, aligning with pediatric dietary guidelines for vegetarians to
ensure adequate growth and development.
3. Question: A nurse is caring for a child who has sickle cell anemia. Which of
the following findings is a priority for the nurse to report to the provider?
Answer: a. Facial twitching
Rationale: Facial twitching in a child with sickle cell anemia may indicate a
neurological complication, such as a stroke, due to vaso-occlusion in cerebral
blood vessels. This is a medical emergency requiring immediate reporting to the
provider. Other findings, like pain or fever, are common but less urgent unless
severe. Stroke risk is significant in sickle cell disease, and early intervention can
prevent long-term damage, making facial twitching the priority finding to address
promptly.
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,4. Question: A nurse is caring for a 1-month-old infant who weighs 3540 g and is
prescribed a dose of cefazolin 50 mg/kg IV bolus TID. How many mg should the
nurse administer per dose?
Answer: 177 mg
Rationale: To calculate the dose, multiply the infant’s weight (3540 g = 3.54 kg) by
the prescribed dose (50 mg/kg): 3.54 kg × 50 mg/kg = 177 mg per dose. This
ensures the infant receives the correct antibiotic amount for effective treatment
while avoiding toxicity. Accurate weight-based dosing is critical in pediatric care to
account for rapid growth and metabolism, aligning with pharmacological safety
standards.
5. Question: A nurse in the PACU is caring for a school-aged child immediately
after a tonsillectomy. Which of the following actions should the nurse take?
Answer: a. Place the child in a side-lying position
Rationale: After a tonsillectomy, placing the child in a side-lying position promotes
drainage of oral secretions and prevents aspiration, a critical concern due to
postoperative bleeding risk. This position also maintains airway patency. Other
actions, like encouraging swallowing, may increase bleeding risk. The side-lying
position aligns with postoperative care standards to ensure safety and comfort
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, while minimizing complications in the immediate recovery period for pediatric
patients.
6. Question: A nurse is performing a pre-college assessment on an adolescent.
Which of the following immunizations should the nurse anticipate
administering?
Answer: a. Meningococcal polysaccharide vaccine
Rationale: Adolescents require the meningococcal vaccine (MCV4) before college
due to increased risk of meningococcal disease in communal settings like
dormitories. This vaccine is typically administered at ages 11–12 with a booster at
16–18, aligning with pre-college assessments. Other vaccines, like Tdap, may also
be given, but MCV4 is a priority. This aligns with CDC immunization schedules to
prevent outbreaks in high-risk settings.
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