Questions and answers
1. The nurse is caring for a 3-year old child who is 2 hours postop from a cardiac catheterization via the
right femoral artery. Which assessment finding is an indication of arterial obstruction?
a.Blood pressure trend is downward and pulse is rapid and irregular.
b.Right foot is cool to the touch and appears pale and blanched.
c.Pulse distal to the femoral artery is weaker on the left foot than right foot.
d.The pressure dressing at right femoral area is moist and oozing blood. - VERIFIED ANS b.Right foot is
cool to the touch and appears pale and blanched.
2. Following a motor vehicle collision, a 3-year old girl has a spica cast applied. Which toy is best for the
nurse for this 3-year-old child?
A. Duckthatsqueaks.
B. Fashiondollandclothes.
C. Set of cloth and hand puppets.
D. Hand held video game. - VERIFIED ANS C. Set of cloth and hand puppets.
3. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the
nurse implement first?
A. Administer morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position.
D. Provide 100% oxygen by face mask. - VERIFIED ANS C. Place the infant in a knee-chest position.
4. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse
determines that the increased respiratory rate is a compensatory mechanism for which acid base
alteration?
A. Metabolicalkalosis.
,B. Respiratory acidosis.
C. Respiratoryalkalosis.
D. Metabolic acidosis. - VERIFIED ANS D. Metabolic acidosis.
5. 7 years old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to
low intermittent suction is applied. Which finding is most important for the nurse to report to the
healthcare provider?
A. Gastric output of 100 mL in the last 8 hours.
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
C. Serum potassium of 3.0 mg/dL.
D. Serum pH of 7.45. - VERIFIED ANS C. Serum potassium of 3.0 mg/dL.
6. The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing
which food indicates that the teaching has been effective?
A. Creamed corn.
B. Pancakes.
C. Rye crackers.
D. Cooked oatmeal. - VERIFIED ANS A. Creamed corn.
7. During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the
block. Which normal growth and development milestone is the baby developing?
A. Separation anxiety.
B. Associativeplay.
C. Object prehension.
D. Object permanence. - VERIFIED ANS D. Object permanence.
, 8. The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes
that the FOC has increased 5 inches since birth and the child's head appears large in relation to body
size. Which action is most important for the nurse to take next?
A. Measuretheinfant'shead-to-toelength.
B. Palpate the anterior fontanel for tension and bulging.
C. Observe the infant for sunken eyes.
D. Plot the measurement on the infant's growth chart. - VERIFIED ANS B. Palpate the anterior fontanel for
tension and bulging.
9. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-
old sibling are at the child's bedside. Which instruction best supports family?
A. While waiting for the healthcare provider, only one visitor may stay with the child.
B. All of you should leave while the healthcare provider sutures the child's forehead.
C. It is best if the sibling goes to the waiting room until the suturing is completed.
D. Please decide who will stay when the healthcare provider begins suturing. - VERIFIED ANS D. Please
decide who will stay when the healthcare provider begins suturing.
10. The nurse is planning for a 5-month old with gastroesophageal reflux disease whose weight has
decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease
vomiting, what instructions should the nurse provide this mother?
A. Givesmallamountsofbabyfoodwitheachfeeding.
B. Thicken formula with cereal for each feeding.
C. Dilute the child's formula with equal parts of water.
D. Offer 10 % dextrose in water between most feedings. - VERIFIED ANS B. Thicken formula with cereal
for each feeding.
11. While teaching a parenting class to new parents the nurse describes the needs of infants and
toddlers regarding discipline and limit setting. What is the most important reason for implementing such
parenting behaviors?