Question 1:
A nurse in a provider's office is preparing to administer vaccinations to a
toddler during a well-child visit. The toddler has an increased respiratory
rate, increased heart rate, and an allergy to Neomycin. Which action should
the nurse plan to take?
A. Withhold the measles, mumps, and rubella (MMR) vaccine.
B. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine.
C. Withhold the influenza vaccine.
D. Withhold the tuberculin skin test (TST).
Answer: A. Withhold the measles, mumps, and rubella (MMR) vaccine.
Rationale: An allergy to neomycin with an anaphylactic reaction is a
contraindication for receiving the MMR vaccine. Clients who have a severe
allergy to eggs or gelatin should also not receive this vaccine.
Question 2:
A nurse is providing teaching to the parent of a school-aged child who has
a new prescription for oral nystatin for the treatment of oral candidiasis.
Which instruction should the nurse include?
A. "Shake the medication prior to administration."
B. "Provide the medication through a straw."
C. "Rinse the child's mouth with water immediately after giving the
,medication."
D. "Mix the medication with applesauce if the child dislikes the taste."
Answer: A. "Shake the medication prior to administration."
Rationale: Shaking the medication ensures the medication is dispersed
evenly within the suspension for proper dosage.
Question 3:
A nurse is reviewing the lumbar puncture results of a school-aged child
who has suspected bacterial meningitis. Which finding should the nurse
identify as an indication of bacterial meningitis?
A. Decreased cerebrospinal fluid pressure
B. Decreased WBC count
C. Increased protein concentration
D. Increased glucose level
Answer: C. Increased protein concentration
Rationale: Increased protein concentration in the cerebrospinal fluid is a
key indicator of bacterial meningitis.
Question 4:
A nurse is caring for a preschooler whose father is going home for a few
hours while another relative stays with the child. Which statement should
the nurse make to explain to the child when their father will return?
A. "Your daddy will be back at 7 p.m."
,B. "Your daddy will be back after you eat."
C. "Your daddy will be back in the morning."
D. "Your daddy will be back after he takes care of your brother."
Answer: B. "Your daddy will be back after you eat."
Rationale: Preschoolers understand time better when associated with daily
routines like meals.
Question 5:
A nurse is reviewing the laboratory report of a school-aged child who is
experiencing fatigue. Which of the following findings should the nurse
recognize as an indication of anemia?
A. Hematocrit 28%
B. Hemoglobin 13.5 g/dL
C. WBC count 8,000/mm³
D. Platelets 250,000/mm³
Answer: A. Hematocrit 28%
Rationale: A hematocrit level of 28% is below the expected reference
range of 32% to 44% for a school-aged child, indicating anemia.
Question 6:
A nurse is reviewing the laboratory results of an infant receiving treatment
for severe dehydration. Which lab value indicates that treatment is
effective?
, A. Potassium 2.9 mEq/L
B. Sodium 140 mEq/L
C. Urine specific gravity 1.035
D. BUN 25 mg/dL
Answer: B. Sodium 140 mEq/L
Rationale: A sodium level of 140 mEq/L is within the expected reference
range of 134 to 150 mEq/L, indicating effective dehydration treatment.
Question 7:
A nurse is reviewing the laboratory report of a 7-year-old child undergoing
chemotherapy. Which of the following lab values should the nurse report to
the provider?
A. Hemoglobin 8.5 g/dL
B. WBC count 9,500/mm³
C. Prealbumin 18 mg/dL
D. Platelets 300,000/mm³
Answer: A. Hemoglobin 8.5 g/dL
Rationale: A hemoglobin level of 8.5 g/dL is below the expected range of
10 to 15.5 g/dL and should be reported due to the risk of anemia.
Question 8:
A nurse is teaching the parents of an infant about preventing sudden infant
death syndrome (SIDS). Which instruction should the nurse include?