NR 328 Exam #2 Practice Questions
4 year old is receiving vaccine. What is the best approach?
a. Before giving the vaccine, give the information about the vaccine.
b. Explain that the pain will be only be a minute & it will be over quickly.
c. Ask the caregiver to step outside and have a nurse aide help.
d. Give the child a syringe to hold, a simple explanation, reassurance. - Answer Answer:
D
Rationale: The nurse should understand that the child is frightened; therefore asking the
parent to step out of the room would further increase the child's anxiety. the first two
options would not allow for the child to interact with the equipment, which is important
as most preschoolers desire concrete vocabulary and interaction with medical
equipment. allowing the child to hold and touch the equipment while offering an
explanation is the best option.
A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed
any meconium stools. What disease should the nurse suspect?
a. Hirschsprung disease
b. Intussusception
c. Celiac disease
d. Pyloric stenosis - Answer Answer: A
Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old infant
include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric
stenosis would present with vomiting but not distention or failure to pass meconium
stools. Intussusception presents with abdominal cramping and celiac disease presents
with malabsorption.
A 3-month-old infant has a hypercyanotic spell while the mother is holding him. What
should the nurse teach the room to do first?
a. Assess for neurologic defects.
b. Do nothing--it will go away.
c. Begin cardiopulmonary resuscitation.
d. Place the child in the knee-chest position. - Answer Answer: D
A 3-year-old boy is seen in the clinic at 8:30 pm with a history of vomiting for 2 days and
poor oral intake; he has voided once since the previous day. Examination reveals a
lethargic child sitting on the mother's lap. He has a capillary refill of 4 seconds, apical
heart rate of 128, respiratory rate of 32, and poor skin turgor. Stated body weight is 25
kg. Based on this information, the nurse anticipates performing which of the following?
A. Demonstrating to the mother how to give 5 to 10 ml of Pedialyte by mouth every 5 to
10 minutes
B. Administering an intravenous fluid bolus of 450 ml of 5% dextrose in water over 60
minutes
C. Administering an intravenous fluid bolus of 500 ml of 0.9% normal saline over 20
minutes
D. Administering an intravenous fluid bolus of 1000 ml of 5% dextrose and 0.45%
normal saline over 30 minutes - Answer Answer: C
,NR 328 Exam #2 Practice Questions
A 4-day-old infant is seen in the emergency department for a possible seizure earlier in
the day. The infant was being breastfed but without much success, so an aunt gave him
a bottle of water. The infant continued to cry, and the mother was too exhausted to
breastfeed, so another bottle of water was given while someone went to the store to
purchase infant formula. The pregnancy, delivery, and postpartum history reveal no
particular problems for this term infant that might contribute to seizures. The physical
examination is unremarkable, with the exception of hypertonic reflexes. The infant is
awake, alert, and sucking on his fists. Diagnostic studies are obtained, including an
electrocardiogram. The nurse anticipates which of the following as the possible
explanation for the infant's condition?
A. Serum potassium of 3.9 mEq
B. Serum glucose of 69 mg
C. Serum sodium of 118 mEq
D. Arterial pH of 7.34 - Answer Answer: C
A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure
to grow. His birth weight was 7 lb, and he now weighs 8 lb, 10 oz. The infant's mother
reports that he is taking 4 to 7 oz of formula every 4 to 5 hours, but he "spits up a lot
after eating and then is hungry again." The child is noted to be alert but appears
malnourished. The mother reports that his stools are brown in color, and he has 1 to 2
bowel movements every day. Based on these findings, the nurse anticipates the infant
has:
A. Meckel diverticulum
B. Hypertrophic pyloric stenosis
C. Intussusception
D. Hirschprung disease - Answer Answer: B
A 6-year-old child with Nephrotic Syndrome is being transferred out of the intensive care
unit. Which child, in light of this diagnosis, is the most appropriate roommate for this
child?
a. 5-year-old child with a fractured femur
b. 6-year-old child with pneumonia
c. 4-year-old child with gastroenteritis
d. 7-year-old child who has undergone surgery for a ruptured appendix - Answer
Answer: A
Rationale: The 5-year-old orthopedic patient is the best choice of roommate. This child
does not have an illness of viral or bacterial origin. A child with pneumonia or
gastroenteritis has an illness of viral or bacterial origin and should not be placed in the
same room as a child with Nephrotic Syndrome. A child who has had surgery for a
ruptured appendix may have an illness of viral or bacterial origin and should not be
placed in the same room as a child with Nephrotic Syndrome.
A 10-year-old child suffered extensive second- and third-degree burns in an apartment
fire. His weight is 75 lb (34 kg). Fluid replacement therapy will optimally:
A. Result in an hourly urine output of 1 ml/kg
B. Result in an hourly urine output of 20 ml/kg
,NR 328 Exam #2 Practice Questions
C. Result in an hourly urine output of 30 ml/kg
D. Maintain a systolic blood pressure in the 95th percentile for the child's weight -
Answer Answer: C
A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received
intravenous fluids, has tolerated some oral fluids in the emergency department, and is
being discharged home. Instructions for diet for this child should include:
A. BRAT diet (bananas, rice, applesauce, and toast) for 24 hours, then a soft diet as
tolerated
B. Chicken or beef broth for 24 hours, then resume a soft diet
C. Offer a regular diet as child's appetite warrants
D. Keep on clear liquids and toast for 24 hours - Answer Answer: C
A burn injury involving the epidermis and varying degrees of the dermal layer that is
painful, moist, red, and blistered describes which of the following?
A. Superficial or first-degree burn
B. Partial-thickness or second-degree burn
C. Full-thickness or third-degree burn
D. Fourth-degree burn - Answer Answer: B
A child is admitted with acute glomerulonephritis. What should the nurse expect the
urinalysis during this acute phase to show?
a. Hematuria and proteinuria
b. Bacteriuria and hematuria
c. Bacteriuria and increased specific gravity
d. Proteinuria and decreased specific gravity - Answer Answer: A
Rationale: Urinalysis during the acute phase characteristically shows hematuria,
proteinuria, and increased specific gravity. Proteinuria generally parallels the hematuria
but is not usually the massive proteinuria seen in nephrotic syndrome. Gross
discoloration of urine reflects its red blood cell and hemoglobin content. Microscopic
examination of the sediment shows many red blood cells, leukocytes, epithelial cells,
and granular and red blood cell casts. Bacteria are not seen, and urine culture results
are negative.
A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to
the pediatric unit. The child is being examined for acute glomerulonephritis. Which of
the following nursing measures should be considered? Select all that apply.
A. On examination there is usually a mild to moderate elevation in blood pressure
compared with normal values for age, although severe hypertension may be present.
B. Urinalysis during the acute phase characteristically shows hematuria, proteinuria,
and increased specific gravity.
C. The primary objective is to reduce the excretion of urinary protein and maintain
protein-free urine.
D. Assessment of the child's appearance for signs of cerebral complications is an
important nursing function because the severity of the acute phase is variable and
unpredictable.
, NR 328 Exam #2 Practice Questions
E. Because these children are particularly vulnerable to upper respiratory tract infection,
protect them from contact with infected roommates, family, or visitors. - Answer
Answers: A, B, D
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for
what potential complication?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Hyperchloremia
d. Hyperkalemia - Answer Answer: A
Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from the loss
of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic
alkalosis, not acidosis, is likely.
A formerly preterm infant who had surgery for necrotizing enterocolitis is now 6 months
old and has short-bowel syndrome. He is unable to absorb most nutrients taken by
mouth and is totally dependent on parenteral nutrition, which he receives via a central
venous catheter. The clinic nurse following this infant is aware that this infant should be
closely observed for the development of:
A. Gastroesophageal reflux
B. Chronic diarrhea
C. Cholestasis
D. Failure to thrive - Answer Answer: C
A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which finding
would the nurse expect at this age?
a. Skips and hops on one foot
b. Stands on one foot for a few seconds
c. Has a vocabulary of 1,500 words
d. Walks backwards heel to toe - Answer Answer: B
Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for
a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.The
other responses are appropriate for 4 & 5 year olds.
A nurse is assessing a child who has a UTI. Which of the following are manifestations of
a UTI? SATA
a. Night sweats
b. Swelling of the face
c. Pallor
d. Pale-colored urine
e. Fatigue - Answer Answers: B, C, E
A nurse is assessing a child who has chronic renal failure. Which of the following
findings should the nurse expect?
a. Flushed face
b. Hyperactivity
4 year old is receiving vaccine. What is the best approach?
a. Before giving the vaccine, give the information about the vaccine.
b. Explain that the pain will be only be a minute & it will be over quickly.
c. Ask the caregiver to step outside and have a nurse aide help.
d. Give the child a syringe to hold, a simple explanation, reassurance. - Answer Answer:
D
Rationale: The nurse should understand that the child is frightened; therefore asking the
parent to step out of the room would further increase the child's anxiety. the first two
options would not allow for the child to interact with the equipment, which is important
as most preschoolers desire concrete vocabulary and interaction with medical
equipment. allowing the child to hold and touch the equipment while offering an
explanation is the best option.
A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed
any meconium stools. What disease should the nurse suspect?
a. Hirschsprung disease
b. Intussusception
c. Celiac disease
d. Pyloric stenosis - Answer Answer: A
Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old infant
include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric
stenosis would present with vomiting but not distention or failure to pass meconium
stools. Intussusception presents with abdominal cramping and celiac disease presents
with malabsorption.
A 3-month-old infant has a hypercyanotic spell while the mother is holding him. What
should the nurse teach the room to do first?
a. Assess for neurologic defects.
b. Do nothing--it will go away.
c. Begin cardiopulmonary resuscitation.
d. Place the child in the knee-chest position. - Answer Answer: D
A 3-year-old boy is seen in the clinic at 8:30 pm with a history of vomiting for 2 days and
poor oral intake; he has voided once since the previous day. Examination reveals a
lethargic child sitting on the mother's lap. He has a capillary refill of 4 seconds, apical
heart rate of 128, respiratory rate of 32, and poor skin turgor. Stated body weight is 25
kg. Based on this information, the nurse anticipates performing which of the following?
A. Demonstrating to the mother how to give 5 to 10 ml of Pedialyte by mouth every 5 to
10 minutes
B. Administering an intravenous fluid bolus of 450 ml of 5% dextrose in water over 60
minutes
C. Administering an intravenous fluid bolus of 500 ml of 0.9% normal saline over 20
minutes
D. Administering an intravenous fluid bolus of 1000 ml of 5% dextrose and 0.45%
normal saline over 30 minutes - Answer Answer: C
,NR 328 Exam #2 Practice Questions
A 4-day-old infant is seen in the emergency department for a possible seizure earlier in
the day. The infant was being breastfed but without much success, so an aunt gave him
a bottle of water. The infant continued to cry, and the mother was too exhausted to
breastfeed, so another bottle of water was given while someone went to the store to
purchase infant formula. The pregnancy, delivery, and postpartum history reveal no
particular problems for this term infant that might contribute to seizures. The physical
examination is unremarkable, with the exception of hypertonic reflexes. The infant is
awake, alert, and sucking on his fists. Diagnostic studies are obtained, including an
electrocardiogram. The nurse anticipates which of the following as the possible
explanation for the infant's condition?
A. Serum potassium of 3.9 mEq
B. Serum glucose of 69 mg
C. Serum sodium of 118 mEq
D. Arterial pH of 7.34 - Answer Answer: C
A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure
to grow. His birth weight was 7 lb, and he now weighs 8 lb, 10 oz. The infant's mother
reports that he is taking 4 to 7 oz of formula every 4 to 5 hours, but he "spits up a lot
after eating and then is hungry again." The child is noted to be alert but appears
malnourished. The mother reports that his stools are brown in color, and he has 1 to 2
bowel movements every day. Based on these findings, the nurse anticipates the infant
has:
A. Meckel diverticulum
B. Hypertrophic pyloric stenosis
C. Intussusception
D. Hirschprung disease - Answer Answer: B
A 6-year-old child with Nephrotic Syndrome is being transferred out of the intensive care
unit. Which child, in light of this diagnosis, is the most appropriate roommate for this
child?
a. 5-year-old child with a fractured femur
b. 6-year-old child with pneumonia
c. 4-year-old child with gastroenteritis
d. 7-year-old child who has undergone surgery for a ruptured appendix - Answer
Answer: A
Rationale: The 5-year-old orthopedic patient is the best choice of roommate. This child
does not have an illness of viral or bacterial origin. A child with pneumonia or
gastroenteritis has an illness of viral or bacterial origin and should not be placed in the
same room as a child with Nephrotic Syndrome. A child who has had surgery for a
ruptured appendix may have an illness of viral or bacterial origin and should not be
placed in the same room as a child with Nephrotic Syndrome.
A 10-year-old child suffered extensive second- and third-degree burns in an apartment
fire. His weight is 75 lb (34 kg). Fluid replacement therapy will optimally:
A. Result in an hourly urine output of 1 ml/kg
B. Result in an hourly urine output of 20 ml/kg
,NR 328 Exam #2 Practice Questions
C. Result in an hourly urine output of 30 ml/kg
D. Maintain a systolic blood pressure in the 95th percentile for the child's weight -
Answer Answer: C
A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received
intravenous fluids, has tolerated some oral fluids in the emergency department, and is
being discharged home. Instructions for diet for this child should include:
A. BRAT diet (bananas, rice, applesauce, and toast) for 24 hours, then a soft diet as
tolerated
B. Chicken or beef broth for 24 hours, then resume a soft diet
C. Offer a regular diet as child's appetite warrants
D. Keep on clear liquids and toast for 24 hours - Answer Answer: C
A burn injury involving the epidermis and varying degrees of the dermal layer that is
painful, moist, red, and blistered describes which of the following?
A. Superficial or first-degree burn
B. Partial-thickness or second-degree burn
C. Full-thickness or third-degree burn
D. Fourth-degree burn - Answer Answer: B
A child is admitted with acute glomerulonephritis. What should the nurse expect the
urinalysis during this acute phase to show?
a. Hematuria and proteinuria
b. Bacteriuria and hematuria
c. Bacteriuria and increased specific gravity
d. Proteinuria and decreased specific gravity - Answer Answer: A
Rationale: Urinalysis during the acute phase characteristically shows hematuria,
proteinuria, and increased specific gravity. Proteinuria generally parallels the hematuria
but is not usually the massive proteinuria seen in nephrotic syndrome. Gross
discoloration of urine reflects its red blood cell and hemoglobin content. Microscopic
examination of the sediment shows many red blood cells, leukocytes, epithelial cells,
and granular and red blood cell casts. Bacteria are not seen, and urine culture results
are negative.
A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to
the pediatric unit. The child is being examined for acute glomerulonephritis. Which of
the following nursing measures should be considered? Select all that apply.
A. On examination there is usually a mild to moderate elevation in blood pressure
compared with normal values for age, although severe hypertension may be present.
B. Urinalysis during the acute phase characteristically shows hematuria, proteinuria,
and increased specific gravity.
C. The primary objective is to reduce the excretion of urinary protein and maintain
protein-free urine.
D. Assessment of the child's appearance for signs of cerebral complications is an
important nursing function because the severity of the acute phase is variable and
unpredictable.
, NR 328 Exam #2 Practice Questions
E. Because these children are particularly vulnerable to upper respiratory tract infection,
protect them from contact with infected roommates, family, or visitors. - Answer
Answers: A, B, D
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for
what potential complication?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Hyperchloremia
d. Hyperkalemia - Answer Answer: A
Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from the loss
of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic
alkalosis, not acidosis, is likely.
A formerly preterm infant who had surgery for necrotizing enterocolitis is now 6 months
old and has short-bowel syndrome. He is unable to absorb most nutrients taken by
mouth and is totally dependent on parenteral nutrition, which he receives via a central
venous catheter. The clinic nurse following this infant is aware that this infant should be
closely observed for the development of:
A. Gastroesophageal reflux
B. Chronic diarrhea
C. Cholestasis
D. Failure to thrive - Answer Answer: C
A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which finding
would the nurse expect at this age?
a. Skips and hops on one foot
b. Stands on one foot for a few seconds
c. Has a vocabulary of 1,500 words
d. Walks backwards heel to toe - Answer Answer: B
Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for
a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.The
other responses are appropriate for 4 & 5 year olds.
A nurse is assessing a child who has a UTI. Which of the following are manifestations of
a UTI? SATA
a. Night sweats
b. Swelling of the face
c. Pallor
d. Pale-colored urine
e. Fatigue - Answer Answers: B, C, E
A nurse is assessing a child who has chronic renal failure. Which of the following
findings should the nurse expect?
a. Flushed face
b. Hyperactivity
