ANSWERS 2025
A nurse is planning care for a newly admitted school-age child who has generalized
seizure disorder. Which of the following interventions should the nurse plan to
include? - CORRECT ANSWER- Ensure the oxygen source is functioning in the
child's room.
The nurse should recognize that maintaining the child's airway is important during a
seizure. The nurse should ensure that the oxygen source is functioning because the
child might require supplemental oxygen following a seizure.
A nurse is providing dietary teaching to the guardian of a school-age child who has
cystic fibrosis. Which of the following statements should the nurse make? -
CORRECT ANSWER- "You should offer your child high-protein meals and snacks
throughout the day."
The nurse should instruct the guardian to provide a diet that is well-balanced and high
in protein and calories. Children who have cystic fibrosis require a higher percentage
of the recommended dietary allowances of all nutrients to meet their energy
requirements. Children who have good nutritional intake have improved lung function
and decreased risk of infection.
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is
postoperative following hypospadias repair with a stent placement. Which of the
following instructions should the nurse include in the teaching? - CORRECT
ANSWER- "Allow the stent to drain directly into your infant's diaper."
The nurse should instruct the parents to ensure that the stent drains directly into the
infant's diaper to prevent kinking or twisting that can interfere with urine flow.
A nurse is caring for a school-age child who has primary nephritic syndrome and is
taking prednisone. Following 1 week of treatment, which of the following
manifestations indicates to the nurse that the medication is effective? - CORRECT
ANSWER- Decreased edema
A child who has nephritic syndrome can experience edema due to the increased
glomerular permeability, which increases protein loss. Prednisone decreases
, glomerular permeability, which causes fluid to shift from the extracellular spaces,
resulting in decreased edema.
A nurse is receiving change-of-shift report for four children. Which of the following
children should the nurse assess first? - CORRECT ANSWER- A toddler who has a
concussion and an episode of forceful vomiting
When using the urgent vs. nonurgent approach to client care, the nurse should assess
this child first. An episode of forceful vomiting is an indication of increased
intracranial pressure in a toddler who has a concussion.
A nurse is providing discharge teaching to the guardians of a toddler who had a lower
leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of
the following findings to the provider? - CORRECT ANSWER- Restricted ability to
move the toes
The nurse should inform the guardians that a restricted ability of the toddler to move
their toes is an indication of neurovascular compromise and requires immediate
notification of the provider. Permanent muscle and tissue damage can occur in just a
few hours.
A nurse in an emergency department is auscultating the lungs of an adolescent who is
experiencing dyspnea. The nurse should identify the sound as which of the following?
(Click on the audio button to listen to the clip.) - CORRECT ANSWER- Wheezes
The nurse should identify the sound during auscultation as wheezes, which are high-
pitched, musical or whistling-like sounds heard primarily on expiration as air passes
through and vibrates narrowed airways.
Notes:
The nurse should identify crackles as high-pitched, short, and noncontinuous sounds
usually heard at the end of inspiration. Crackles occur when air expands deflated
alveoli or when the passage of air through small airways is disrupted.
The nurse should identify a pleural friction rub as a loud, rough, grating sound that
can be heard during inspiration or expiration. A pleural friction rub occurs when the
pleurae are inflamed and the surfaces rub together.
The nurse should identify rhonchi as low-pitched, continuous sounds that have a
snore-like quality and are usually louder during expiration. Rhonchi occur when the
larger airways are obstructed.