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60 Questions And Answers
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1. Anurseiscontributingtotheplanofcareforapreschoolerwhohasmoder- ate
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partial-thickness burns on both lower extremities.Which of the following
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interventions should the nurse recommend?
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Ans >> : Ensure the child receives pain medication 30 to 45 min prior to therapy.
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Rationale Thenurseshouldensurethatthepreschoolerreceivespainmedication30to ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
45min prior to physical therapy sessions.The nurse should monitor the child's pain
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levels andtreatthemasneeded.Thiswillminimizeoreliminatepainfrommovingtightskin
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atjoints,whichwillencouragethechildtoparticipateinphysicaltherapy.Ifthechild isin
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painduring therapy,itwillbeachallengetogetthe childtoparticipate in future sessions.
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2. A nurse is assisting with care for an adolescent client who has asthma and a new
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prescription for albuterol by metered-dose inhaler. Which of the following
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statements by the client indicates that they might be experiencing an adverse
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effect of albuterol?
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Ans >>:"My heart feels like it's fluttering after taking my medication,"
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Rationale The nurse should identify that the client might be experiencing palpitations or
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,/ tachycardia, common adverse effects of albuterol. ,/ ,/ ,/ ,/ ,/
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,3. Anurseinaprovider'sofficeiscollectingdatafromanadolescentwhohas
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juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6
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months.Which of the following client statements should the nurse report to the
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provider?
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Ans >>: "Inoticed some blood in my stool this morning."
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Rationale The nurse should identify that bloody stools are an adverse effect of long-
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term therapywith ibuprofen.The nurse shouldquestion the adolescentregarding anew
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onset of abdominal pain and should report the client's statement to the provider.
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4. A nurse is reinforcing teaching with the parent of a child who has diabetes
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mellitus.The parent asks the nurse how to minimize the child's pain when
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monitoring blood glucose levels.Which of the following statements by the
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parent indicates an understanding of the teaching?
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Ans >>:"My child should hold their finger under warm water before obtaining a sample.
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Rationale Holding the finger under warm water will'promote blood flow to the finger,
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making the puncture less painful.
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5. Anurseisreinforcingteachingwiththeparentofachildwhohasabacterial upper
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respiratory infection.Which of the following statements by the parent indicates
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an understanding of the teaching?: "I will keep my child's towels separate from
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those of the rest of the family."
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, Rationale Thenurseshouldidentifythatachildwhohasanupperrespiratoryinfection ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
should use separate towels, utensils, and cups to prevent the infection from spreading.
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6. A nurse is contributing to the plan of care for a child who has nephrotic
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syndromeandaprescriptionforcorticosteroids.Whichofthefollowinginter-
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ventions should the nurse recommend?
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Ans >>: Provide a low-sodium diet.
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Rationale Thenurseshouldrecommendprovidingthechildwithalow-sodiumdietto ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
decrease edema associated with nephrotic syndrome.
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7. A nurse is collecting data from a child who recently experienced a psy-
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chomotorseizure.Which of the following findings should the nurse expect?-
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Ans >>:Amnesia ,/ ,/
Rationale Thenurseshouldidentifythatamnesiaisanexpectedmanifestationaftera ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
seizure. Children often do not remember the seizure activity.
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8. A nurse is collecting data from a 5-month-old infant who is postoperative
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followingumbilicalherniarepair.Whichofthefollowingmeasuresshouldthe
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nurse use to evaluate the infant's pain level?
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Ans >>: FLACC pain rating scale
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Rationale ThenurseshouldusetheFLACCpainratingscaletoevaluatethisinfant'spain ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
level following outpatient surgery to repair an umbilical hernia.The FLACC scale is a
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postoperativepainratingtoolusedforchildrenrangingfrom2monthsoldto7years old.
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TheacronymstandsforFace,Legs,Activity,Cry,andConsolability.Thescoring ranges
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from 0, indicating "no pain behaviors" to 10, indicating "most possible pain behaviors."
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9. A nurse is assisting in the admission of a 9-month-old infant who has
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gastroenteritiswith vomiting and diarrhea.Which ofthe following findings is
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the nurse's priority? (Click on the exhibit tabs for additional information about
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the client.There are three tabs that contain separate categories of data.)
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Ans >>: Potassium level ,/ ,/ ,/
Rationale When using the urgent vs.nonurgent approach to client care, the nurse ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/ ,/
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