1. A 3-year-old child is brought to the emergency department with a sudden onset of high
fever, drooling, and a muffled voice. The child is sitting in a tripod position. Which nursing
action is the priority?
A. Keep the child calm and avoid any invasive procedures
B. Assess the throat using a tongue depressor
C. Administer a dose of oral acetaminophen
D. Place the child in a supine position for easier breathing
Answer: A
Rationale: These are classic signs of epiglottitis. Any agitation or throat examination can
trigger complete airway obstruction. The child should be kept calm until an emergency
airway is established.
2. A nurse is caring for an infant with Tetralogy of Fallot who suddenly becomes cyanotic and
dyspneic. Which position should the nurse place the infant in immediately?
A. High Fowler’s
B. Knee-chest
C. Trendelenburg
D. Prone
,Answer: B
Rationale: In a ‘Tet spell,’ the knee-chest position increases systemic vascular resistance,
which decreases the right-to-left shunt and improves oxygenation.
3. The nurse is providing education to the parents of a child with Cystic Fibrosis. Which
instruction regarding pancreatic enzyme replacement is correct?
A. Administer enzymes two hours after meals
B. Administer enzymes only with the morning and evening meals
C. Administer enzymes with every meal and snack
D. Skip the enzymes if the child is having a high-fat meal
Answer: C
Rationale: Pancreatic enzymes are necessary to digest fats and proteins and must be taken
with all meals and snacks to ensure proper absorption.
4. A 2-year-old is hospitalized with Laryngotracheobronchitis (Croup). Which clinical
manifestation is most characteristic of this condition?
A. Wheezing on expiration
B. Absent breath sounds in the lower lobes
C. Productive cough with thick green sputum
D. High-pitched, barking cough
Answer: D
, Rationale: Croup is characterized by edema of the larynx and trachea, resulting in a
distinct brassy, barking cough and inspiratory stridor.
5. A nurse is assessing an 8-week-old infant suspected of having pyloric stenosis. Which
finding is the hallmark of this condition?
A. Bile-stained emesis
B. Currant jelly-like stools
C. Chronic constipation and abdominal distension
D. Projectile vomiting after feedings
Answer: D
Rationale: Hypertrophic pyloric stenosis causes a narrowing of the pyloric sphincter,
leading to forceful, non-bilious projectile vomiting.
6. The nurse is caring for a child with Intussusception. Which type of stool does the nurse
expect to find documented in the child’s record?
A. Ribbon-like, foul-smelling stools
B. Bloody mucus, currant jelly-like stools
C. Hard, pebble-like stools
D. Steatorrhea (fatty stools)
Answer: B