NR 328 STANDARD EXAMS ANSWERS AND
QUESTIONS SET A+
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse
knows that before this young woman can be examined, consent must be obtained from
which source? - ✔✔Herself
✔✔The nurse needs to take the blood pressure of a preschool boy for the first time.
What action would be best in gaining his cooperation? - ✔✔Permit him to handle the
equipment and see the cuff inflate and deflate before putting the cuff in place.
✔✔A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back.
Her mother puts the hospital gown on her, but the child is crying because she wants to
leave on her underpants. What is the most appropriate nursing action at this time?? -
✔✔Allow her to wear her underpants.
✔✔Using knowledge of child development, what approach is best when preparing a
toddler for a procedure? - ✔✔Demonstrate on a doll how the procedure will be done.
✔✔The nurse is preparing a 9-year-old boy before obtaining a blood specimen by
venipuncture. The child tells the nurse he does not want to lose his blood. What
approach is best by the nurse? - ✔✔Discuss with him how his body is always in the
process of making blood.
✔✔A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother
to hold her during the procedure. How should the nurse respond? - ✔✔Holding may
help your child relax.
✔✔A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed
tomography scan of the abdomen. To encourage the child to drink, what should the
nurse do? - ✔✔Use little cups and make a game to reward him for each cup he drinks.
,✔✔A toddler is being sent to the operating room for surgery at 9 AM. As the nurse
prepares the child, what is the priority intervention? - ✔✔Verifying that the child and
procedure are correct
✔✔A 5-year-old child returns from the pediatric intensive care unit after abdominal
surgery. The orders state to monitor vital signs every 2 hours. On assessment, the
nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively.
What should be the nurses next action? - ✔✔Recheck the pulse and blood pressure in
15 minutes.
✔✔A 10-year-old child requires daily medications for a chronic illness. Her mother tells
the nurse that the child continually forgets to take the medicine unless reminded. What
nursing action is most appropriate to promote adherence to the medication regimen? -
✔✔Establish a contract with her, including rewards.
✔✔A 7-year-old is identified as being at risk for skin breakdown. What intervention
should the nursing care plan include? - ✔✔Ensuring that nutritional intake meets
requirements
✔✔A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little
on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and
ice cream. What nursing action is the most appropriate? - ✔✔Request these favorite
foods for him.
✔✔A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry
represents best documentation of his breakfast meal? - ✔✔One pancake, eggs, and
240 ml OJ
✔✔A child, age 7 years, has a fever associated with a viral illness. She is being cared
for at home. What is the principal reason for treating fever in this child? - ✔✔Relief of
discomfort
✔✔A critically ill child has hyperthermia. The parents ask the nurse to give an
antipyretic such as acetaminophen. How should the nurse respond to the parents? -
✔✔Antipyretics are of no value in treating hyperthermia.
✔✔The nurse gives an injection in a patients room. How should the nurse dispose of
the needle? - ✔✔Dispose of the syringe and needle in a rigid, puncture-resistant
container in the patients room.
✔✔A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-
resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in
addition to a private room, the child is placed on what precautions? - ✔✔Contact
,✔✔An 11-month-old hospitalized boy is restrained because he is receiving intravenous
(IV) fluids. His grandmother has come to stay with him for the afternoon and asks the
nurse if the restraints can be removed. What nurses response is best? - ✔✔That is fine
as long as you are with him.
✔✔A nurse must do a venipuncture on a 6-year-old child. What consideration is
important in providing atraumatic care? - ✔✔Show the child the equipment to be used
before the procedure.
✔✔A 2-year-old child is being admitted to the hospital for possible bacterial meningitis.
When preparing for a lumbar puncture, what should the nurse do? - ✔✔Prepare the
child for conscious sedation being used for the procedure.
✔✔Frequent urine tests for specific gravity are required on a 6-month-old infant. What
method is the most appropriate way to collect small amounts of urine for these tests? -
✔✔Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
✔✔A child has a central venous access device for intravenous (IV) fluid administration.
A blood sample is needed for a complete blood count, hemogram, and electrolytes.
What is the appropriate procedure to implement for this blood sample? - ✔✔Withdraw a
blood sample equal to the amount of fluid in the device, discard, and then withdraw the
sample needed.
✔✔The nurse has just collected blood by venipuncture in the antecubital fossa. What
should the nurse do next? - ✔✔Keep the childs arm extended and apply pressure to the
site for a few minutes.
✔✔An appropriate method for administering oral medications that are bitter to an infant
or small child should be to mix them with which? - ✔✔One teaspoon of something
sweet-tasting such as jam
✔✔The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media.
The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in
teaching the mother how to give the medicine? - ✔✔A hollow-handled medication spoon
is advisable, and the medication should be equally spaced while the child is awake.
✔✔Guidelines for intramuscular administration of medication in school-age children
include what standard? - ✔✔Insert needle quickly, using a dartlike motion.
✔✔What is an advantage of the ventrogluteal muscle as an injection site in young
children? - ✔✔Free of significant nerves and vascular structures
, ✔✔When teaching a mother how to administer eye drops, where should the nurse tell
her to place them? - ✔✔In the conjunctival sac when the lower eyelid is pulled down
✔✔What is the best method to verify the placement of a nasogastric tube before each
use? - ✔✔Aspiration of stomach contents
✔✔Parents are being taught how to feed their infant using a newly placed gastrostomy
tube (G-tube). What is essential information for the parents to receive? - ✔✔Position the
infant on the right side during and after the feeding.
✔✔What is a priority intervention for an infant with a temporary colostomy for
Hirschsprung disease? - ✔✔Protecting the skin around the colostomy
✔✔A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old
and single and lives with her parents. Who signs the informed consent for the 1-month-
old infant? - ✔✔The infants mother
✔✔A preschool child needs a dressing change. To prepare the child, what strategy
should the nurse implement? - ✔✔Give choices when possible but avoid delay.
✔✔The nurse on a pediatric unit is writing guidelines for age-specific preparation of
children for procedures based on developmental characteristics. What guideline is
accurate? - ✔✔Use simple diagrams of anatomy and physiology to explain a procedure
to a school-age child.
✔✔A laboratory technician is performing a blood draw on a toddler. The toddler is
holding still but crying loudly. The nurse should take which action? - ✔✔Do nothing. Its
Okay for a child to cry during a painful procedure.
✔✔At which age should a nurse keep teaching time short (5 minutes)? - ✔✔Toddler
✔✔The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever.
What nursing action is appropriate? - ✔✔Check to be sure the Tylenol dose does not
exceed 15 mg/kg.
✔✔The nurse is administering an IM injection into a vastus lateralis muscle of a 6-
month-old infant. What should the length of the needle and amount to be given be? -
✔✔5/8 to 1 inch; 0.5 to 1.0 ml
✔✔The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin
administering intravenous antibiotics. The child starts to cry and tells the nurse, Do it
later, okay? What action should the nurse take? - ✔✔Start the IV line and then allow for
expression of feelings.
QUESTIONS SET A+
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse
knows that before this young woman can be examined, consent must be obtained from
which source? - ✔✔Herself
✔✔The nurse needs to take the blood pressure of a preschool boy for the first time.
What action would be best in gaining his cooperation? - ✔✔Permit him to handle the
equipment and see the cuff inflate and deflate before putting the cuff in place.
✔✔A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back.
Her mother puts the hospital gown on her, but the child is crying because she wants to
leave on her underpants. What is the most appropriate nursing action at this time?? -
✔✔Allow her to wear her underpants.
✔✔Using knowledge of child development, what approach is best when preparing a
toddler for a procedure? - ✔✔Demonstrate on a doll how the procedure will be done.
✔✔The nurse is preparing a 9-year-old boy before obtaining a blood specimen by
venipuncture. The child tells the nurse he does not want to lose his blood. What
approach is best by the nurse? - ✔✔Discuss with him how his body is always in the
process of making blood.
✔✔A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother
to hold her during the procedure. How should the nurse respond? - ✔✔Holding may
help your child relax.
✔✔A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed
tomography scan of the abdomen. To encourage the child to drink, what should the
nurse do? - ✔✔Use little cups and make a game to reward him for each cup he drinks.
,✔✔A toddler is being sent to the operating room for surgery at 9 AM. As the nurse
prepares the child, what is the priority intervention? - ✔✔Verifying that the child and
procedure are correct
✔✔A 5-year-old child returns from the pediatric intensive care unit after abdominal
surgery. The orders state to monitor vital signs every 2 hours. On assessment, the
nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively.
What should be the nurses next action? - ✔✔Recheck the pulse and blood pressure in
15 minutes.
✔✔A 10-year-old child requires daily medications for a chronic illness. Her mother tells
the nurse that the child continually forgets to take the medicine unless reminded. What
nursing action is most appropriate to promote adherence to the medication regimen? -
✔✔Establish a contract with her, including rewards.
✔✔A 7-year-old is identified as being at risk for skin breakdown. What intervention
should the nursing care plan include? - ✔✔Ensuring that nutritional intake meets
requirements
✔✔A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little
on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and
ice cream. What nursing action is the most appropriate? - ✔✔Request these favorite
foods for him.
✔✔A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry
represents best documentation of his breakfast meal? - ✔✔One pancake, eggs, and
240 ml OJ
✔✔A child, age 7 years, has a fever associated with a viral illness. She is being cared
for at home. What is the principal reason for treating fever in this child? - ✔✔Relief of
discomfort
✔✔A critically ill child has hyperthermia. The parents ask the nurse to give an
antipyretic such as acetaminophen. How should the nurse respond to the parents? -
✔✔Antipyretics are of no value in treating hyperthermia.
✔✔The nurse gives an injection in a patients room. How should the nurse dispose of
the needle? - ✔✔Dispose of the syringe and needle in a rigid, puncture-resistant
container in the patients room.
✔✔A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-
resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in
addition to a private room, the child is placed on what precautions? - ✔✔Contact
,✔✔An 11-month-old hospitalized boy is restrained because he is receiving intravenous
(IV) fluids. His grandmother has come to stay with him for the afternoon and asks the
nurse if the restraints can be removed. What nurses response is best? - ✔✔That is fine
as long as you are with him.
✔✔A nurse must do a venipuncture on a 6-year-old child. What consideration is
important in providing atraumatic care? - ✔✔Show the child the equipment to be used
before the procedure.
✔✔A 2-year-old child is being admitted to the hospital for possible bacterial meningitis.
When preparing for a lumbar puncture, what should the nurse do? - ✔✔Prepare the
child for conscious sedation being used for the procedure.
✔✔Frequent urine tests for specific gravity are required on a 6-month-old infant. What
method is the most appropriate way to collect small amounts of urine for these tests? -
✔✔Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
✔✔A child has a central venous access device for intravenous (IV) fluid administration.
A blood sample is needed for a complete blood count, hemogram, and electrolytes.
What is the appropriate procedure to implement for this blood sample? - ✔✔Withdraw a
blood sample equal to the amount of fluid in the device, discard, and then withdraw the
sample needed.
✔✔The nurse has just collected blood by venipuncture in the antecubital fossa. What
should the nurse do next? - ✔✔Keep the childs arm extended and apply pressure to the
site for a few minutes.
✔✔An appropriate method for administering oral medications that are bitter to an infant
or small child should be to mix them with which? - ✔✔One teaspoon of something
sweet-tasting such as jam
✔✔The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media.
The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in
teaching the mother how to give the medicine? - ✔✔A hollow-handled medication spoon
is advisable, and the medication should be equally spaced while the child is awake.
✔✔Guidelines for intramuscular administration of medication in school-age children
include what standard? - ✔✔Insert needle quickly, using a dartlike motion.
✔✔What is an advantage of the ventrogluteal muscle as an injection site in young
children? - ✔✔Free of significant nerves and vascular structures
, ✔✔When teaching a mother how to administer eye drops, where should the nurse tell
her to place them? - ✔✔In the conjunctival sac when the lower eyelid is pulled down
✔✔What is the best method to verify the placement of a nasogastric tube before each
use? - ✔✔Aspiration of stomach contents
✔✔Parents are being taught how to feed their infant using a newly placed gastrostomy
tube (G-tube). What is essential information for the parents to receive? - ✔✔Position the
infant on the right side during and after the feeding.
✔✔What is a priority intervention for an infant with a temporary colostomy for
Hirschsprung disease? - ✔✔Protecting the skin around the colostomy
✔✔A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old
and single and lives with her parents. Who signs the informed consent for the 1-month-
old infant? - ✔✔The infants mother
✔✔A preschool child needs a dressing change. To prepare the child, what strategy
should the nurse implement? - ✔✔Give choices when possible but avoid delay.
✔✔The nurse on a pediatric unit is writing guidelines for age-specific preparation of
children for procedures based on developmental characteristics. What guideline is
accurate? - ✔✔Use simple diagrams of anatomy and physiology to explain a procedure
to a school-age child.
✔✔A laboratory technician is performing a blood draw on a toddler. The toddler is
holding still but crying loudly. The nurse should take which action? - ✔✔Do nothing. Its
Okay for a child to cry during a painful procedure.
✔✔At which age should a nurse keep teaching time short (5 minutes)? - ✔✔Toddler
✔✔The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever.
What nursing action is appropriate? - ✔✔Check to be sure the Tylenol dose does not
exceed 15 mg/kg.
✔✔The nurse is administering an IM injection into a vastus lateralis muscle of a 6-
month-old infant. What should the length of the needle and amount to be given be? -
✔✔5/8 to 1 inch; 0.5 to 1.0 ml
✔✔The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin
administering intravenous antibiotics. The child starts to cry and tells the nurse, Do it
later, okay? What action should the nurse take? - ✔✔Start the IV line and then allow for
expression of feelings.
