Question 1
The nurse is educating a client about how to use a metered-dose inhaler with spacer.
Drag and drop the options below in the order that demonstrates correct use of a metered-
dose inhaler with spacer.
A. Remove the mouthpiece from the lips
B. Breathe out slowly
C. Breathe in deeply
D. Hold breath for 10 seconds
E. Release the medication into the spacer
CORRECT ANSWER
E, C, A, D, B
Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then
hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended
when inhalers are used because they increase the availability of the medication to the
client.
Question 2
The nurse is caring for a 10 month-old infant diagnosed with iron-deficiency anemia.
Based on this diagnosis, which of these findings should the nurse anticipate?
A. Poor appetite
B. Hemoglobin level of 12 g/dL
C. A heart rate between 80 and 130
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,D. Pale mucosa of the eyelids and lips
CORRECT ANSWER
D
In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with
mild-to-severe tachycardia. The normal heart rate of infants typically ranges from 120 to
180 BPM. The normal hemoglobin range for children is about 11 to 13 gm/dL.
Question 3
The clinic nurse is caring for a 15 month-old child with a first episode of otitis media.
Which intervention should the nurse include in the instructions to the child's parents?
A. Explain that the child should complete the full five days of antibiotics
B. Describe the tympanocentesis to detect persistent infections
C. Emphasize the importance of a return visit after completion of antibiotics
D. Provide them with handout describing care of myringotomy tubes
CORRECT ANSWER
C
The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should
be examined again after completion of the full course of antibiotics to assess for
persistent infection or middle ear effusion.
Question 4
A client is admitted to a voluntary hospital mental health unit with the diagnosis of
suicidal ideation. The client has been on the unit for two days and now states, "I demand
to be released now!" The appropriate response from the nurse should be which of these
statements?
A. "You have a right to sign out as soon as we get the health care provider's discharge order."
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,B. "You cannot be released because you are still at risk of being suicidal."
C. "Let's discuss your decision to leave and then we can prepare you for discharge."
D. "You can be released only if you sign a no suicide contract before you leave."
CORRECT ANSWER
C
Clients who are voluntarily admitted to the hospital have a right to demand and obtain
release. By discussing the decision to leave the nurse has an opportunity to suggest or
implement interventions other than discharge. The client may just need to talk through
thoughts or feelings.
Question 5
The nurse assesses a client who has been taking haloperidol for several months. Which
adverse effect must be immediately reported to the health care provider?
A. Constipation
B. Dry, harsh cough
C. Tongue thrusting and facial grimacing
D. Muscle flaccidity
CORRECT ANSWER
C
Dystonias often involve tongue protrusions and muscle rigidity. Dystonias usually resolve
after the medication is discontinued, but the client may require antihistamine and
antiparkinsonian therapy. Dystonic movements have the potential of becoming
irreversible and must be immediately reported to the health care provider. Some of the
more common side effects of haloperidol include nausea, vomiting, diarrhea, dry mouth,
nervousness, drowsiness, insomnia, and blurred vision.
Question 6
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, A nurse is teaching a class for new parents at a local community center. Which activity
would the nurse stress as being the most hazardous for an 8 month-old?
A. Jumping on a bed
B. Eating whole peanuts
C. Playing around electrical outlets
D. Riding in a car
CORRECT ANSWER
D
Car accidents are a leading cause of death in babies and children, as well as a major
cause of permanent brain damage and spinal cord injury. Although all the other options
pose a danger to young children, drowning is actually the second most common cause of
accidental death among children.
Question 7
A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of
irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch.
The child sits leaning forward, tongue protruding, drooling and has suprasternal
retractions What should the nurse do first?
A. Notify the health care provider of the child's status
B. Collect a sputum specimen
C. Examine the child's throat
D. Prepare the child for x-ray of upper airways
CORRECT ANSWER
A
These findings suggest epiglottitis, which is a medical emergency. Any child with an acute
onset of an inflammatory response in the mouth and throat should receive immediate
medical attention in a facility equipped to perform intubation or a tracheostomy in the
event of further or complete obstruction.
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The nurse is educating a client about how to use a metered-dose inhaler with spacer.
Drag and drop the options below in the order that demonstrates correct use of a metered-
dose inhaler with spacer.
A. Remove the mouthpiece from the lips
B. Breathe out slowly
C. Breathe in deeply
D. Hold breath for 10 seconds
E. Release the medication into the spacer
CORRECT ANSWER
E, C, A, D, B
Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then
hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended
when inhalers are used because they increase the availability of the medication to the
client.
Question 2
The nurse is caring for a 10 month-old infant diagnosed with iron-deficiency anemia.
Based on this diagnosis, which of these findings should the nurse anticipate?
A. Poor appetite
B. Hemoglobin level of 12 g/dL
C. A heart rate between 80 and 130
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,D. Pale mucosa of the eyelids and lips
CORRECT ANSWER
D
In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with
mild-to-severe tachycardia. The normal heart rate of infants typically ranges from 120 to
180 BPM. The normal hemoglobin range for children is about 11 to 13 gm/dL.
Question 3
The clinic nurse is caring for a 15 month-old child with a first episode of otitis media.
Which intervention should the nurse include in the instructions to the child's parents?
A. Explain that the child should complete the full five days of antibiotics
B. Describe the tympanocentesis to detect persistent infections
C. Emphasize the importance of a return visit after completion of antibiotics
D. Provide them with handout describing care of myringotomy tubes
CORRECT ANSWER
C
The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should
be examined again after completion of the full course of antibiotics to assess for
persistent infection or middle ear effusion.
Question 4
A client is admitted to a voluntary hospital mental health unit with the diagnosis of
suicidal ideation. The client has been on the unit for two days and now states, "I demand
to be released now!" The appropriate response from the nurse should be which of these
statements?
A. "You have a right to sign out as soon as we get the health care provider's discharge order."
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,B. "You cannot be released because you are still at risk of being suicidal."
C. "Let's discuss your decision to leave and then we can prepare you for discharge."
D. "You can be released only if you sign a no suicide contract before you leave."
CORRECT ANSWER
C
Clients who are voluntarily admitted to the hospital have a right to demand and obtain
release. By discussing the decision to leave the nurse has an opportunity to suggest or
implement interventions other than discharge. The client may just need to talk through
thoughts or feelings.
Question 5
The nurse assesses a client who has been taking haloperidol for several months. Which
adverse effect must be immediately reported to the health care provider?
A. Constipation
B. Dry, harsh cough
C. Tongue thrusting and facial grimacing
D. Muscle flaccidity
CORRECT ANSWER
C
Dystonias often involve tongue protrusions and muscle rigidity. Dystonias usually resolve
after the medication is discontinued, but the client may require antihistamine and
antiparkinsonian therapy. Dystonic movements have the potential of becoming
irreversible and must be immediately reported to the health care provider. Some of the
more common side effects of haloperidol include nausea, vomiting, diarrhea, dry mouth,
nervousness, drowsiness, insomnia, and blurred vision.
Question 6
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, A nurse is teaching a class for new parents at a local community center. Which activity
would the nurse stress as being the most hazardous for an 8 month-old?
A. Jumping on a bed
B. Eating whole peanuts
C. Playing around electrical outlets
D. Riding in a car
CORRECT ANSWER
D
Car accidents are a leading cause of death in babies and children, as well as a major
cause of permanent brain damage and spinal cord injury. Although all the other options
pose a danger to young children, drowning is actually the second most common cause of
accidental death among children.
Question 7
A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of
irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch.
The child sits leaning forward, tongue protruding, drooling and has suprasternal
retractions What should the nurse do first?
A. Notify the health care provider of the child's status
B. Collect a sputum specimen
C. Examine the child's throat
D. Prepare the child for x-ray of upper airways
CORRECT ANSWER
A
These findings suggest epiglottitis, which is a medical emergency. Any child with an acute
onset of an inflammatory response in the mouth and throat should receive immediate
medical attention in a facility equipped to perform intubation or a tracheostomy in the
event of further or complete obstruction.
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