UPDATED VERSION 2025 WITH
CORRECT QUESTION AND ANSWERS
AEnurseEisEaEprovidersEofficeEisEpreparingEtoEadministerEvaccinationsEtoEaEtoddlerEdur
ingEaEwell-
childEvisit.EWhichEofEtheEactionsEshouldEtheEnurseEplanEtoEtake?E(kidEhasEincreasedER
RE&EHR;EallergyEtoENeomycin)
A. WithholdEtheEmeasles,Emumps,EandErubellaE(MMR)Evaccine.
B. WithholdEtheEdiphtheria,Etetanus,EandEpertussisE(DTaP)Evaccine.
C. WithholdEtheEinfluenzaEvaccine.
D. WithholdEtheEtuberculinEskinEtestE(TST).E-
EA.EWithholdEtheEmeasles,Emumps,EandErubellaE(MMR)Evaccine.
Rationale:ETheEnurseEshouldErecognizeEthatEanEallergyEtoEneomycinEwithEanEanaphyl
acticEreactionEisEaEcontraindicationEforEreceivingEtheEMMREvaccine.EClientsEwhoEhave
EaEsevereEallergyEtoEeggsEorEgelatinEshouldEnotEreceiveEthisEvaccine.
AEnurseEisEprovidingEteachingEtoEtheEparentEofEaEschool-
agedEchildEwhoEhasEaEnewEprescriptionEforEoralEnystatinEforEtheEtreatmentEofEoralEcan
didacies.EWhichEofEtheEfollowingEinstructionsEshouldEtheEnurseEinclude?
A. "ShakeEtheEmedicationEpriorEtoEadministration."
B. "ProvideEtheEmedicationEthroughEaEstraw."
C. "RinseEtheEchild'sEmouthEwithEwaterEimmediatelyEafterEgivingEtheEmedication."
D. "MixEtheEmedicationEwithEapplesauceEifEtheEchildEdislikesEtheEtaste."E-
EA.E"ShakeEtheEmedicationEpriorEtoEadministration."
Rationale:ETheEnurseEshouldEinstructEtheEparentEtoEshakeEtheEmedicationEpriorEtoEad
ministrationEtoEdisperseEtheEmedicationEevenlyEwithinEtheEsuspension.
AEnurseEisEreviewingEtheElumbarEpunctureEresultsEofEaEschool-
agedEchildEwhoEhasEsuspectedEbacterialEmeningitis.EWhichEofEtheEfollowingEfindingsE
shouldEtheEnurseEidentifyEasEanEindicationEofEbacterialEmeningitis?
A. DecreasedEcerebrospinalEfluidEpressure
B. DecreasedEWBCEcount
C. IncreasedEproteinEconcentration
D. IncreasedEglucoseElevelE-EC.EIncreasedEproteinEconcentration
Rationale:ETheEnurseEshouldEidentifyEthatEanEincreasedEproteinEconcentrationEinEtheE
spinalEfluidEisEaEfindingEthatEcanEindicateEbacterialEmeningitis.
AEnurseEisEcaringEforEaEpreschoolerEwhoseEfatherEisEgoingEhomeEhomeEforEaEfewEhou
rsEwhileEanotherErelativeEstaysEwithEtheEchild.EWhichEofEtheEfollowingEstatementsEsho
uldEtheEnurseEmakeEtoEexplainEtoEtheEchildEwhenEtheirEfatherEwillEreturn?
A. "YourEdaddyEwillEbeEbackEatE7Ep.m."
B. "YourEdaddyEwillEbeEbackEafterEyouEeat."
C. "YourEdaddyEwillEbeEbackEinEtheEmorning."
D. "YourEdaddyEwillEbeEbackEafterEheEtakesEcareEofEyourEbrother."E-
EB.E"YourEdaddyEwillEbeEbackEafterEyouEeat."
Rationale:EPreschoolersEmakeEsenseEofEtimeEbestEwhenEtheyEcanEassociateEitEwithEa
nEexpectedEdailyEroutine,EsuchEasEmealsEandEbedtime.ETherefore,EtheEchildEcompreh
endsEtimeEbestEwhenEitEisEexplainedEtoEthemEinErelationEtoEanEeventEtheyEareEfamiliar
Ewith,EsuchEasEeating.
, AEnurseEisEreviewingEtheElaboratoryEreportEofEaEschool-
agedEchildEwhoEisEexperiencingEfatigue.EWhichEofEtheEfollowingEfindingsEshouldEtheEn
urseErecognizeEasEanEindicationEofEanemia?
A. HematocritE28%
B. HemoglobinE13.5Eg/dL
C. WBCEcountE8,000/mm3
D. PlateletsE250,000/mm3E-EA.EHematocritE28%
Rationale:ETheEnurseEshouldErecognizeEthatEthisEhematocritElevelEisEbelowEtheEexp
ectedEreferenceErangeEofE32%EtoE44%EforEaEschool-
ageEchild.ETheEchildEcanEexhibitEfatigue,Elightheadedness,Etachycardia,Edyspnea,E
andEpallorEdueEtoEtheEdecreasedEoxygen-carryingEcapacity.
AEnurseEisEreviewingEtheElaboratoryEresultsEofEanEinfantEwhoEisEreceivingEtreatmentEfo
rEsevereEdehydration.ETheEnurseEshouldEidentifyEwhichEofEtheEfollowingElabEvaluesEin
dicatesEthatEtheEtreatmentEisEworking?
A. PotassiumE2.9EmEq/L
B. SodiumE140EmEq/L
C. UrineEspecificEgravityE1.035
D. BUNE25Emg/dLE-EB.ESodiumE140EmEq/L
Rationale:ETheEnurseEshouldEidentifyEthatEaEsodiumElevelEofE140EmEq/LEisEwithinEt
heEexpectedEreferenceErangeEofE134EtoE150EmEq/LEandEindicatesEtheEcurrentEtreat
mentEregimenEtheEinfantEisEreceivingEforEdehydrationEisEeffective.
AEnurseEisEreviewingEtheElaboratoryEreportEofEaE7-year-
oldEchildEwhoEisEgoingEthroughEchemotherapy.EwhichEofEtheEfollowingElabEvaluesEsho
uldEtheEnurseEreportEtoEtheEprovider?
A. HgbE8.5Eg/dL
B. WBCEcountE9,500/mm3
C. PrealbuminE18Emg/dL
D. PlateletsE300,000/mm3E-EA.EHgbE8.5Eg/dL
Rationale:EAEchildEreceivingEchemotherapyEisEatEriskEforEanemiaEdueEtoEtheEchemoth
erapyEeffectsEonEtheEblood-
formingEcellsEofEtheEboneEmarrow.ETheEdevelopmentEofEanemiaEisEdiagnosedEthroug
hElaboratoryEtestingEofEhemoglobinEandEhematocritElevels.ETheEnurseEshouldErecogni
zeEthatEaEhemoglobinElevelEofE8.5Eg/dLEisEbelowEtheEexpectedEreferenceErangeEofE10E
toE15.5Eg/dLEforEaE7-year-oldEchildEandEshouldEbeEreportedEtoEtheEprovider.
AEnurseEisEteachingEtheEparentsEofEanEinfantEwaysEtoEpreventEsuddenEinfantEdeathEsy
ndromeE(SIDS).EWhichEofEtheEfollowingEinstructionsEshouldEtheEnurseEinclude?
A. "PlaceEtheEinfantEinEaEproneEpositionEtoEsleep."
B. "AllowEtheEinfantEtoEsleepEonEaElargeEpillow."
C. "UseEaEsoftEmattressEinEtheEinfant'sEcrib."
D. "GiveEtheEinfantEaEpacifierEatEbedtime."E-
ED.E"GiveEtheEinfantEaEpacifierEatEbedtime."ERationale:ETheEnurseEshouldEinformEtheE
parentEthatEprotectiveEfactorsEagainstESIDSEincludeEbreastfeedingEandEtheEuseEofEa
EpacifierEwhenEtheEinfantEisEsleeping.
AEnurseEisEcaringEforEaEpreschoolerEwhoEhasEbeenEreceivingEIVEfluidsEviaEaEperiphera
lEIVEcatheter.EWhenEpreparingEtoEdiscontinueEtheEIVEfluidsEandEcatheter,EwhichEofEth
eEfollowingEactionsEshouldEtheEnurseEplanEtoEtake?E(placeEinEorder)
RemoveEtheEtapeEsecuringEtheEcatheter