QUESTIONS 7 COMPLETE
SOLUTIONS
A preschooler has a small laceration that required 2 stitches. The nurse covers the
wound with a bandage knowing that it will comfort the child to have it covered. What is
the developmental reason for this intervention?
A. Preschoolers are magical thinkers and imagine bandages keep their insides from
coming out
B. Preschoolers fear physical disability and believe a bandage will prevent disability
C. Preschoolers explore orally and will likely chew or suck on the stitches if left
uncovered
D. Preschoolers are concerned with body image and don't want to appear different than
peers - ANSWER
A 7-month-old presents to the emergency department with a complaint of fever.
Assessment reveals a patent airway and slight cyanosis around his lips and nail beds.
He is alert and interactive. His vital signs are 38.5 °C (101.3 °F), HR 134, RR 32, BP
78/54 mm Hg, and SpO2 84%. The nurse notes a healed surgical scar on his chest.
Based on this assessment, what is the nurse's priority?
A. Administer ibuprofen to treat the fever
B. Begin oxygen via a nonrebreather mask
C. Obtain a surgical history
D. Ask if the SpO2 is normal for him - ANSWER
An 11-year-old presents to the emergency department with a complaint of hitting his
head while playing soccer. The nurse enters the room and performs an across-the-room
assessment. He is staring at the wall. He has no increased work of breathing, and his
color is pink. Using the pediatric assessment triangle (PAT), what classification will the
nurse assign?
A. Well
B. Sick
C. Sicker
D. Sickest - ANSWER
The pediatric prioritization process components include the focused assessment,
focused history, acuity rating decision and:
A. the pediatric assessment triangle (PAT).
B. developmental characteristics.
C. head-to-toe assessment.
D. life-saving interventions. - ANSWER
, A 2-year-old is brought to the emergency department by her father when he found her
face down in the pool. She remains unresponsive and is breathing shallowly and slowly.
Her color is pale. What is the priority?
A. Administer 100% oxygen
B. Immobilize the cervical spine
C. Begin bag-mask ventilation
D. Insert an oral airway - ANSWER
A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal
alignment, padding should be placed under which area?
A. Shoulders
B. Head
C. Neck
D. Waist - ANSWER
The nurse is preparing to administer a feeding through a nasogastric feeding tube. The
tube position was verified by radiograph after insertion 2 hours ago. How will the nurse
verify placement before feeding?
A. Instill air and listen over the epigastrium
B. Test the pH of the gastric contents
C. Observe color of a gastric aspirate sample.
D. Repeat the radiograph - ANSWER
A neonate is delivered in the emergency department and placed on a radiant warmer.
There is no staining of the amniotic fluid. What is the first step in neonatal resuscitation?
A. Dry and warm the neonate
B. Suction the mouth and nose
C. Assess for effective breathing
D. Palpate a central pulse rate - ANSWER
In discussing the legal care of the adolescent patient, what is a mature minor?
A. A minor who lives independently and is legally able to make health decisions
B. A minor who is able to make decisions regarding his or her own sexual or mental
health
C. A minor who is able to make decisions regarding health care as a parent of his or her
own child
D. A minor who lives with a parent or guardian but legally is able to make health
decisions - ANSWER
Which of the following screening statements/questions is most appropriate in assessing
an adolescent for dating violence?
A. "What triggers violence you've experienced from your partner?"
B. "Does your partner feel entitled to sex even if you say 'no'?"
C. "Tell me about a time when you've felt unsafe in your relationship."