Graded A+ Answers
1. A00mother00brings00her00800mo.00old00baby00boy00to00clinic00bc00he00
has00been00vomitting00and00had00diarrhea00for00last00300days.00Which00
assessment00is00most00important00for00nurse00to00make?
a. Assess00infant00abdomen00for00tenderness
b. Determine00if00the00infant00was00exposed00to00a00virus
c. Measure00the00infant’s00pulse
d. Evaluate00the00infant’s00cry
2. While00obtaining00the00vital00signs00of00a001000year00old00who00had00
a00tonsillectomy00this00morning,00the00nurse00observes00the00child00s
wallowing00every002-
300minutes.00Which00assessment00should00the00nurse00implement?00
a.Inspect00the00posterior00oropharynx
b. Assess00for00teeth00clenching00or00grinding
c. Touch00the00tonsillar00pillars00to00stimulate00the00gag00reflex
d. Ask00the00child00to00speak00to00evaluate00change00in00voice00tone
3. The00parents00of00a003-
year00old00boy00who00has00Duchenne00muscular00dystrophy00ask,00
“How00can00our00son00have00this00disease?00We00are00wondering00if
00we00should00have00any00more00children.”00What00information00sho
uld00the00nurse00provide00to00parents?
a. This00is00an00inherited
00X-
00linked00recessive00disorder,00which00primarily00affect
s00male00children0 0 in00the00family
b. The00striated00muscle00groups00of00males00can00be00impacted00
by00a00lack00of00the00protein00dystrophin00in00their00mothers
c. The00male00infant00had00a00viral00infection00that00went00unnoti
ced00and00untreated00so00muscle00damage00was00incurred
d. Birth00trauma00with00a00breech00vaginal00birth00causes00damag
e00to00the00spinal00cord,00thus00weakening00the00muscles
4. A002-week-
old00female00infant00is00hospitalized00for00the00surgical00repair00of00
an00umbilical00hernia.00After00returning00to00the00postoperative00n
eonatal00unit,00her00RR00and00HR00have00increased00during00the00l
,ast00hour.00Which00intervention00should00the00nurse00implement?
, a. Notify00the00HCP00of00these00findings
b. Administer00a00PRN00analgesic00prescription
c. Record00the00findings00in00the00child’s00record
d. Wrap00the00infant00tightly00and00rock00in00rocking00chair
5. A002-year-
old00girl00is00brought00to00the00clinic00by00her001700year00old00mothe
r.00When00the00nurse00observes00that00the00child00is00drinking00swee
tened00soda00from00her00bottle,00what00information00should00the00nu
rse00discuss00with00this00mother?
a. A002-year00old00should00be00speaking00in00200word00phrases
b. Dental00caries00are00associated00with00drinking00soda
c. Drinking00soda00is00related00to00childhood00obesity
d. Toddlers00should00be00sleeping001000hours00a00night
e. Toddlers00should00be00drinking00from00a00cup00by00age002
6. A00mother00brings00her00300month00old00infant00to00the00clinic00becaus
e00the00baby00does00not00sleep00through00the00night.00Which00finding0
0is00most00significant00in00planning00care00for00this00family?
a. The00mother00is00a00single00parent00and00lives00with00her00parents
b. The00mother00states00the00baby00is00irritable00during00feedings
c. The00infant’s00formula00has00been00changed00twice
d. The00diaper00area00shows00severe00skin00breakdown
7. The00nurse00determines00that00an00infant00admitted00for00surgical00rep
air00of00an00inguinal00hernia00voids00a00urinary00stream00from00the00ve
ntral00surface00of00the00penis.00What00action00should00the00nurse00tak
e?
a. Document00the00finding
b. Palpate00scrotum00for00testicular00descent
c. Assess00for00bladder00distension
d. Auscultate00bowel00sounds
8. A001600year00old00with00acute00myelocytic00leukemia00is00rec
eiving00chemotherapy00(CT)00via00an00implanted00medicatio
n00port00at00the00outpatient00oncology00clinic.00What00action
00should00the00nurse00implement00when00the00infusion00is00
complete?
a. Administer00Zofran
b. Obtain00blood00samples00for00RBCs,00WBCs,00and00platelets