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1. A nurse in the emergency department is caring for a 2-yr old child who was
found by his parents crying and holding a container of toilet bowl cleaner.
The child's lips are edematous and inflamed, and he is drooling. Which of
the following is the following priority action by the nurse?
A. Remove the child's contaminated clothing.
B. Check the child's respiratory status.
C. Administer an antidote to the child.
D. Establish IV access for the child. - ANSWER 🗸 b. Check the child's
respiratory status.
Rationale: When applying the ABC priority setting framework, airway is
always the highest priority because the airway must be clear and open for
oxygen exchange to occur. Breathing is the second highest priority in the
ABC priority setting framework because adequate ventilatory effort is
essential in order for oxygen change to occur.
2. A nurse is teaching a parent of a 12-month old child about development
during the toddler years. Which of the following statements should the nurse
include?
A. Your child should be referring to himself using the appropriate
pronoun by the 18 months of age
, B. A toddler's interest in looking at pictures occurs at 20 months of age
C. A toddler should have daytime control of his bowel and bladder by 24
months of age.
D. Your child should be able to scribble spontaneously using a crayon at
the age of 15 months - ANSWER 🗸 d. Your child should be able to
scribble spontaneously using a crayon at the age of 15 months
Rationale: The nurse should teach the parent that at the age of 15 months,
the toddler should be Able to scribble spontaneously, and at the age of 18
months, the toddler should be able to make Strokes imitatively
3. A nurse is caring for a toddler and is preparing to administer 0.9% sodium
chloride 100ml IV to infuse over 4 hr. The drop factor of the manual IV
tubing is 60 gtt/ml. The nurse should set the manual IV infusion to deliver
how many gtt/min? (Round the answer to the nearest whole number) -
ANSWER 🗸 25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
4. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which
of the following actions should the nurse take?
A. Perform the assessment in a head to toe sequence.
B. Minimize physical contact with the child initially.
C. Explain procedures using medical terminology
D. Stop the assessment if the child becomes uncooperative. - ANSWER
🗸 b. Minimize physical contact with the child initially.
Rationale: The nurse should initially minimize physical contact with the
toddler, and then Progress from the least traumatic to the most traumatic
procedures.
5. A nurse is caring for an 18-yr old adolescent who is up to date on
immunizations and is planning to attend college. The nurse should inform
the client that he should receive which of the following immunizations prior
to moving into a campus dormitory.
A. Pneumococcal polysaccharide
B. Meningococcal polysaccharide
, C. Rotavirus
D. Herpes zoster - ANSWER 🗸 b. Meningococcal polysaccharide
Rationale: The meningococcal polysaccharide immunization is used to
prevent infection by
Certain groups of meningococcal bacteria. Meningococcal infection can
cause life-threatening
Illnesses, such as meningococcal meningitis, which affects the brain, and
meningococcemia,
Which affects the blood. Both of these conditions can be fatal. College
freshmen, particularly Those who live in dormitories, are at an increased risk
for meningococcal disease relative to other persons their age. Therefore, the
Centers for Disease Control and Prevention has issued a Recommendation
that all incoming college students receive the meningococcal immunization.
6. A nurse is teaching the parent of an infant about food allergens. Which of
the following foods should the nurse include as being the most common
food allergy in children.
A. Cow's milk
B. Wheat bread
C. Corn syrup
D. Eggs - ANSWER 🗸 a. Cow's milk
Rationale: According to evidence-based practice, the nurse should instruct
the parent that cow's Milk is the most common food allergy in children.
Some children are sensitive to the protein, Called casein, found in cow's
milk. They have difficulty metabolizing the casein and are, Therefore,
allergic to cow's milk.
7. A nurse is teaching the parent of a toddler about home safety. Which of the
following statements by the parent indicates an understanding of the
teaching?
A. I lock my medications in the medicine cabinet
B. I keep my child's crib mattress at the highest level
C. I turn pot handles to the side of my stove while cooking.
, D. I will give my child syrup of ipecac if she swallows something
poisonous. - ANSWER 🗸 a. I lock my medications in the medicine
cabinet
Rationale: Locking up medications and other potential poisons prevents
access. Toddlers have
Improved gross and fine motor skills that allow for further exploration of the
environment and
Possible access to hazardous substances.
8. A nurse is performing a physical assessment on a 6-month old infant. Which
of the following reflexes should the nurse expect to find?
A. Stepping
B. Babinski
C. Extrusion
D. Moro - ANSWER 🗸 b. Babinski
Rationale: The Babinski reflex, which is elicited by stroking the bottom of
the foot and causing
The toes to fan and the big toe to dorsiflex, should be present until the age of
1 year. Persistence
Of neonatal reflexes might indicate neurological deficits.
9. A nurse is preparing to administer recommended immunizations to a 2-
month old infant. Which of the following immunizations should the nurse
plan to administer.
A. Human papilloma virus (HPV) and hepatitis A
B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and
acellular pertussis (tdap)
C. Haemophilus influenza type B (Hib) and inactivated polio virus (IPV)
D. Varicella (VAR) and live attenuated influenza vaccine (LAIV) -
ANSWER 🗸 c. Haemophilus influenza type B (Hib) and inactivated
polio virus (IPV)
Rationale: The recommended immunizations for a 2-month-old infant
include Hib and IPV. The
Hib immunization series consists of 3 to 4 doses, depending on the
immunization used, and at a