Question: 1 of 70
A nurse is preparing to perform tracheostomy care and suctioning for a child. Which of the following actions should the
nurse plan to take?
• Use clean technique to suction the tracheostomy tube.
• Provide humidification through a face mask.
• Apply suction when inserting the catheter into the tracheostomy tube.
• Allow one fingerbreadth beneath the tracheostomy ties.
Answer Rationale
• Correct Answer: Allow one fingerbreadth beneath the tracheostomy ties.
o Rationale: Leaving one fingerbreadth (or one finger space) under the tracheostomy ties ensures
that the ties are secure enough to prevent accidental decannulation or displacement of the
tube, while also preventing skin breakdown, pressure injury, or constriction around the child's
neck
,A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the
following interventions should the nurse include?
• Collect and strain all urine for sediment.
• Monitor blood pressure every 4 hr.
• Implement a protein-restricted diet.
• Increase fluid consumption.
Answer Rationale
• Correct Answer: Monitor blood pressure every 4 hr.
o Rationale: Acute glomerulonephritis causes fluid retention and sodium intravascular
accumulation due to decreased glomerular filtration, leading to hypertension. Frequent
monitoring of vital signs (especially blood pressure every 4 to 6 hours) is critical to
detect and manage hypertensive encephalopathy and cardiovascular complications
,Question: 3 of 70
A nurse is caring for a child who has a prescription for fluticasone and has developed white patches and sores in his
mouth. Which of the following is an appropriate action for the nurse to take?
• Encourage the use of a spacer.
• Obtain a prescription for oral prednisone.
• Withhold the medication until the lesions heal.
• Collect a culture from the lesions.
Answer Rationale
• Correct Answer: Encourage the use of a spacer.
o Rationale: Fluticasone is an inhaled corticosteroid that can cause oral candidiasis (thrush) as a
side effect due to localized immunosuppression in the mouth and pharynx. Using a spacer
reduces drug deposition in the oral cavity by directing more of the medication directly into the
lungs, thereby helping to preven
, A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions
should the nurse include in the plan?
• Bathe the child every other day.
• Obtain the child's rectal temperature once daily.
• Administer vaccines prior to discharge.
• Avoid raw fruits and vegetables in the child's diet.
Answer Rationale
• Correct Answer: Avoid raw fruits and vegetables in the child's diet.
o Rationale: Preschoolers with neutropenia have a severely suppressed immune system,
placing them at high risk for opportunistic infections. Raw fruits and vegetables can
harbor bacteria, molds, and parasites that cannot be entirely washed away; therefore, a
low-microbial (neutropenic) diet requiring all foods to be cooked is recommended to
A nurse is preparing to perform tracheostomy care and suctioning for a child. Which of the following actions should the
nurse plan to take?
• Use clean technique to suction the tracheostomy tube.
• Provide humidification through a face mask.
• Apply suction when inserting the catheter into the tracheostomy tube.
• Allow one fingerbreadth beneath the tracheostomy ties.
Answer Rationale
• Correct Answer: Allow one fingerbreadth beneath the tracheostomy ties.
o Rationale: Leaving one fingerbreadth (or one finger space) under the tracheostomy ties ensures
that the ties are secure enough to prevent accidental decannulation or displacement of the
tube, while also preventing skin breakdown, pressure injury, or constriction around the child's
neck
,A nurse is planning care for a school-age child who has acute glomerulonephritis. Which of the
following interventions should the nurse include?
• Collect and strain all urine for sediment.
• Monitor blood pressure every 4 hr.
• Implement a protein-restricted diet.
• Increase fluid consumption.
Answer Rationale
• Correct Answer: Monitor blood pressure every 4 hr.
o Rationale: Acute glomerulonephritis causes fluid retention and sodium intravascular
accumulation due to decreased glomerular filtration, leading to hypertension. Frequent
monitoring of vital signs (especially blood pressure every 4 to 6 hours) is critical to
detect and manage hypertensive encephalopathy and cardiovascular complications
,Question: 3 of 70
A nurse is caring for a child who has a prescription for fluticasone and has developed white patches and sores in his
mouth. Which of the following is an appropriate action for the nurse to take?
• Encourage the use of a spacer.
• Obtain a prescription for oral prednisone.
• Withhold the medication until the lesions heal.
• Collect a culture from the lesions.
Answer Rationale
• Correct Answer: Encourage the use of a spacer.
o Rationale: Fluticasone is an inhaled corticosteroid that can cause oral candidiasis (thrush) as a
side effect due to localized immunosuppression in the mouth and pharynx. Using a spacer
reduces drug deposition in the oral cavity by directing more of the medication directly into the
lungs, thereby helping to preven
, A nurse is planning care for a preschooler who has neutropenia. Which of the following interventions
should the nurse include in the plan?
• Bathe the child every other day.
• Obtain the child's rectal temperature once daily.
• Administer vaccines prior to discharge.
• Avoid raw fruits and vegetables in the child's diet.
Answer Rationale
• Correct Answer: Avoid raw fruits and vegetables in the child's diet.
o Rationale: Preschoolers with neutropenia have a severely suppressed immune system,
placing them at high risk for opportunistic infections. Raw fruits and vegetables can
harbor bacteria, molds, and parasites that cannot be entirely washed away; therefore, a
low-microbial (neutropenic) diet requiring all foods to be cooked is recommended to
