Test Bank Pediatric Nursing The Critical
Components of Nursing Care 2nd Edition
Rudd |Complete Guide A+
1 — A 2-month-old infant presents with a bulging fontanelle, high fever, and irritability. Which
action should the nurse do first?
A. Offer a cool bath
B. Obtain blood cultures and start antibiotics
C. Give acetaminophen per order
D. Measure head circumference
Answer: B — Suspected meningitis requires prompt cultures and empiric antibiotics after
appropriate specimens.
2 — The best indicator of fluid status in an infant is:
A. Daily weights
B. Skin turgor on the abdomen
C. Number of wet diapers
D. Fontanel condition
Answer: A — Daily weight is the most accurate objective measure of fluid balance.
3 — A preschool child having surgery asks what to expect. The best nursing approach is to:
A. Give a detailed anatomical explanation
B. Use simple, concrete language and play demonstration
C. Tell the child not to worry
D. Ignore the question and talk to parents
Answer: B — Preschoolers need simple, concrete explanations and play to understand.
4 — For a child with croup (viral laryngotracheobronchitis) presenting with inspiratory stridor and
mild retractions, the first-line intervention is:
A. Oral corticosteroids and humidified air
B. Nebulized epinephrine only
, C. IV antibiotics
D. Immediate intubation
Answer: A — Humidified air and corticosteroids reduce airway inflammation; nebulized epi for
severe distress.
5 — A 7-year-old swallowed a button battery 30 minutes ago. The priority is:
A. Observe at home for vomiting
B. Bring child to ED for immediate removal
C. Give milk to coat the esophagus
D. Induce emesis
Answer: B — Button batteries can rapidly cause tissue damage; immediate removal is
required.
6 — A child with congenital heart disease has clubbing of fingers. Clubbing occurs because of:
A. Chronic hypoxemia causing increased vascular connective tissue
B. Dehydration
C. Iron deficiency anemia
D. Excessive calcium intake
Answer: A — Chronic hypoxemia leads to digital clubbing.
7 — Which developmental task is expected of a 15-month-old?
A. Using two-word phrases
B. Walking independently and beginning to run
C. Tying shoelaces
D. Riding a tricycle
Answer: B — By ~12–18 months, most toddlers walk independently and begin to run.
8 — A child with suspected epiglottitis is sitting forward, drooling, and anxious. The nurse
should:
A. Attempt throat culture
B. Keep the child calm and prepare for emergent airway management
C. Place in supine position for exam
D. Offer a drink of water
Answer: B — Epiglottitis can cause sudden airway obstruction; avoid upsetting the child and
prepare for airway.
9 — The safest place for an infant car seat is:
A. Front passenger seat with airbags off
B. Rear center seat, rear-facing for infants
C. Rear-facing in any rear seat attached with lap belt only
D. Booster seat as soon as the child is comfortable
Answer: B — Rear center seat rear-facing is safest for infants.
10 — The nurse is teaching parents about ADHD and medication. An important side effect of
stimulant meds is:
,A. Excessive sedation
B. Appetite suppression and weight loss
C. Hypoglycemia
D. Bradycardia
Answer: B — Stimulants commonly cause decreased appetite and weight loss.
11 — A neonate with persistent hypoglycemia is at risk for:
A. Hyperactivity later in life
B. Seizures and neurodevelopmental impairment
C. Increased height as a toddler
D. Improved feeding skills
Answer: B — Prolonged neonatal hypoglycemia can cause seizures and brain injury.
12 — A child with acute asthma exacerbation has an SpO₂ of 88%. The nurse should:
A. Administer humidified oxygen and monitor
B. Start antibiotics
C. Place in Trendelenburg position
D. Give oral steroids only
Answer: A — Hypoxemia requires oxygen; bronchodilators and steroids also indicated.
13 — Which vaccine is contraindicated for immunocompromised children?
A. Inactivated influenza vaccine
B. MMR (live) vaccine when severely immunocompromised
C. Hepatitis B vaccine
D. DTaP vaccine
Answer: B — Live vaccines like MMR are contraindicated in severe immunosuppression.
14 — The priority nursing assessment for a child with dehydration is:
A. Capillary refill and heart rate
B. Level of play activity
C. Height measurement
D. Sleep patterns
Answer: A — Vital signs and perfusion (heart rate, cap refill) indicate dehydration severity.
15 — A toddler refuses to take oral antibiotics. Best strategy:
A. Force medication into mouth
B. Mix with small amount of favorite food or use flavored formulation
C. Stop medication and wait
D. Give double dose next time
Answer: B — Mixing with small appealing carrier or using flavored meds improves compliance.
16 — A child with nephrotic syndrome is at increased risk for:
A. Hypoalbuminemia and edema
B. Hypertension from hypervolemia only
C. Hypercalcemia
, D. Elevated hemoglobin
Answer: A — Nephrotic syndrome causes protein loss leading to hypoalbuminemia and
edema.
17 — A 10-year-old has a temperature of 39.4°C and generalized tonic-clonic seizure lasting 3
minutes — postictal but stable. The priority nursing action:
A. Administer rectal diazepam immediately
B. Monitor airway and oxygenation and place on side
C. Insert oral airway while seizing
D. Give a cold sponge bath
Answer: B — After a seizure, airway and oxygenation are priorities; benzodiazepines during
prolonged seizure.
18 — The correct technique for measuring a tympanic temperature in a 2-year-old:
A. Pull pinna down and back and insert probe gently
B. Pull pinna up and back
C. Use oral thermometer
D. Tympanic not appropriate for toddlers
Answer: A — For children under 3, pull pinna down and back.
19 — A child with hemophilia presents with a joint bleed. Initial nursing care should include:
A. Apply heat and massage joint
B. RICE: Rest, Ice, Compression, Elevation and administer factor concentrate
C. Encourage active range-of-motion
D. Give high-dose aspirin
Answer: B — RICE and factor replacement are appropriate; avoid NSAIDs like aspirin.
20 — A 4-year-old with suspected appendicitis is lying supine, quiet, with minimal movement.
The nurse recognizes this as:
A. Normal play behavior
B. A sign of peritoneal irritation and possible appendicitis
C. A sign of viral gastroenteritis
D. Anxiety only
Answer: B — Stillness often indicates abdominal pain/peritonitis in children.
21 — For a child receiving ototoxic medication (e.g., aminoglycoside), the nurse should monitor:
A. Renal function and hearing tests (audiology)
B. Blood glucose only
C. Blood pressure
D. Visual acuity
Answer: A — Monitor renal labs and hearing because aminoglycosides are ototoxic and
nephrotoxic.
22 — Best position for a child after tonsillectomy to prevent aspiration is:
A. Prone
Components of Nursing Care 2nd Edition
Rudd |Complete Guide A+
1 — A 2-month-old infant presents with a bulging fontanelle, high fever, and irritability. Which
action should the nurse do first?
A. Offer a cool bath
B. Obtain blood cultures and start antibiotics
C. Give acetaminophen per order
D. Measure head circumference
Answer: B — Suspected meningitis requires prompt cultures and empiric antibiotics after
appropriate specimens.
2 — The best indicator of fluid status in an infant is:
A. Daily weights
B. Skin turgor on the abdomen
C. Number of wet diapers
D. Fontanel condition
Answer: A — Daily weight is the most accurate objective measure of fluid balance.
3 — A preschool child having surgery asks what to expect. The best nursing approach is to:
A. Give a detailed anatomical explanation
B. Use simple, concrete language and play demonstration
C. Tell the child not to worry
D. Ignore the question and talk to parents
Answer: B — Preschoolers need simple, concrete explanations and play to understand.
4 — For a child with croup (viral laryngotracheobronchitis) presenting with inspiratory stridor and
mild retractions, the first-line intervention is:
A. Oral corticosteroids and humidified air
B. Nebulized epinephrine only
, C. IV antibiotics
D. Immediate intubation
Answer: A — Humidified air and corticosteroids reduce airway inflammation; nebulized epi for
severe distress.
5 — A 7-year-old swallowed a button battery 30 minutes ago. The priority is:
A. Observe at home for vomiting
B. Bring child to ED for immediate removal
C. Give milk to coat the esophagus
D. Induce emesis
Answer: B — Button batteries can rapidly cause tissue damage; immediate removal is
required.
6 — A child with congenital heart disease has clubbing of fingers. Clubbing occurs because of:
A. Chronic hypoxemia causing increased vascular connective tissue
B. Dehydration
C. Iron deficiency anemia
D. Excessive calcium intake
Answer: A — Chronic hypoxemia leads to digital clubbing.
7 — Which developmental task is expected of a 15-month-old?
A. Using two-word phrases
B. Walking independently and beginning to run
C. Tying shoelaces
D. Riding a tricycle
Answer: B — By ~12–18 months, most toddlers walk independently and begin to run.
8 — A child with suspected epiglottitis is sitting forward, drooling, and anxious. The nurse
should:
A. Attempt throat culture
B. Keep the child calm and prepare for emergent airway management
C. Place in supine position for exam
D. Offer a drink of water
Answer: B — Epiglottitis can cause sudden airway obstruction; avoid upsetting the child and
prepare for airway.
9 — The safest place for an infant car seat is:
A. Front passenger seat with airbags off
B. Rear center seat, rear-facing for infants
C. Rear-facing in any rear seat attached with lap belt only
D. Booster seat as soon as the child is comfortable
Answer: B — Rear center seat rear-facing is safest for infants.
10 — The nurse is teaching parents about ADHD and medication. An important side effect of
stimulant meds is:
,A. Excessive sedation
B. Appetite suppression and weight loss
C. Hypoglycemia
D. Bradycardia
Answer: B — Stimulants commonly cause decreased appetite and weight loss.
11 — A neonate with persistent hypoglycemia is at risk for:
A. Hyperactivity later in life
B. Seizures and neurodevelopmental impairment
C. Increased height as a toddler
D. Improved feeding skills
Answer: B — Prolonged neonatal hypoglycemia can cause seizures and brain injury.
12 — A child with acute asthma exacerbation has an SpO₂ of 88%. The nurse should:
A. Administer humidified oxygen and monitor
B. Start antibiotics
C. Place in Trendelenburg position
D. Give oral steroids only
Answer: A — Hypoxemia requires oxygen; bronchodilators and steroids also indicated.
13 — Which vaccine is contraindicated for immunocompromised children?
A. Inactivated influenza vaccine
B. MMR (live) vaccine when severely immunocompromised
C. Hepatitis B vaccine
D. DTaP vaccine
Answer: B — Live vaccines like MMR are contraindicated in severe immunosuppression.
14 — The priority nursing assessment for a child with dehydration is:
A. Capillary refill and heart rate
B. Level of play activity
C. Height measurement
D. Sleep patterns
Answer: A — Vital signs and perfusion (heart rate, cap refill) indicate dehydration severity.
15 — A toddler refuses to take oral antibiotics. Best strategy:
A. Force medication into mouth
B. Mix with small amount of favorite food or use flavored formulation
C. Stop medication and wait
D. Give double dose next time
Answer: B — Mixing with small appealing carrier or using flavored meds improves compliance.
16 — A child with nephrotic syndrome is at increased risk for:
A. Hypoalbuminemia and edema
B. Hypertension from hypervolemia only
C. Hypercalcemia
, D. Elevated hemoglobin
Answer: A — Nephrotic syndrome causes protein loss leading to hypoalbuminemia and
edema.
17 — A 10-year-old has a temperature of 39.4°C and generalized tonic-clonic seizure lasting 3
minutes — postictal but stable. The priority nursing action:
A. Administer rectal diazepam immediately
B. Monitor airway and oxygenation and place on side
C. Insert oral airway while seizing
D. Give a cold sponge bath
Answer: B — After a seizure, airway and oxygenation are priorities; benzodiazepines during
prolonged seizure.
18 — The correct technique for measuring a tympanic temperature in a 2-year-old:
A. Pull pinna down and back and insert probe gently
B. Pull pinna up and back
C. Use oral thermometer
D. Tympanic not appropriate for toddlers
Answer: A — For children under 3, pull pinna down and back.
19 — A child with hemophilia presents with a joint bleed. Initial nursing care should include:
A. Apply heat and massage joint
B. RICE: Rest, Ice, Compression, Elevation and administer factor concentrate
C. Encourage active range-of-motion
D. Give high-dose aspirin
Answer: B — RICE and factor replacement are appropriate; avoid NSAIDs like aspirin.
20 — A 4-year-old with suspected appendicitis is lying supine, quiet, with minimal movement.
The nurse recognizes this as:
A. Normal play behavior
B. A sign of peritoneal irritation and possible appendicitis
C. A sign of viral gastroenteritis
D. Anxiety only
Answer: B — Stillness often indicates abdominal pain/peritonitis in children.
21 — For a child receiving ototoxic medication (e.g., aminoglycoside), the nurse should monitor:
A. Renal function and hearing tests (audiology)
B. Blood glucose only
C. Blood pressure
D. Visual acuity
Answer: A — Monitor renal labs and hearing because aminoglycosides are ototoxic and
nephrotoxic.
22 — Best position for a child after tonsillectomy to prevent aspiration is:
A. Prone
