ALREADY GRADED A+
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child
suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication
infusion, which of the following medications should the nurse administer first?
prednisone
epinephrine
diphenhydramine
albuterol - answer-epinephrine
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS).
Which of the following instructions should the nurse include?
"Place the infant in a prone position to sleep."
"Allow the infant to sleep on a large pillow."
"Use a soft mattress in the infant's crib."
"Give the infant a pacifier at bedtime." - answer-"Give the infant a pacifier at bedtime."
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings
should the nurse expect? (Select all the apply)
Negative Babinski reflex
Ankle clonus
Exaggerated stretch reflexes
Uncontrollable movements of the face
Contractures - answer-Ankle clonus
Exaggerated stretch reflexes
Contractures
A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a
cleft palate repair. For which of the following members of the inter professional team should the nurse
initiate a referral?
,occupational therapist
speech therapist
respiratory therapist
physical therapist - answer-speech therapist
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which
of the following interventions should the nurse include in the plan?
Position the infant side-lying with their head at a 0° to 5° angle.
Perform a neurological assessment every 4 hr.
Suction the infant's naers to remove secretions.
Implement seizure precautions for the infant. - answer-Implement seizure precautions for the infant.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the
nurse take?
Place a cardiac monitor on the adolescent prior to the procedure.
Apply topical analgesic cream to the site 1hr prior to the procedure.
Keep the adolescent in a semi-fowler's position for 4hrs following the procedure.
Restrict fluids for 2hrs following procedure. - answer-Apply topical analgesic cream to the site 1hr prior
to the procedure.
A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral
nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse
include?
"Shake the medication prior to administration.".
"Provide the medication through a straw."
"Rinse the child's mouth with water immediately after giving the medication."
"Mix the medication with applesauce if the child dislikes the taste." - answer-"Shake the medication
prior to administration."
A nurse in an emergency department is performing a physical assessment on a 2 week old male
newborn. Which of the following findings is priority for the nurse to report to the provider?
,excoriated scrotal area
multiple capillary hemangiomas
depressed posterior fontanel
substernal retractions - answer-substernal retractions
A nurse is receiving change-of-shift report on four children. Which of the following children should the
nurse see first?
A school age child who has sickle cell anemia and reports decreased vision in the left eye.
School age child who has cystic fibrosis and a frequent nonproductive cough.
A preschooler who has asthma and a peak flow meter reading in the green zone.
An adolescent who has meningitis and reports a sensitivity to lights and noise. - answer-A school age
child who has sickle cell anemia and reports decreased vision in the left eye.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority
for the nurse to report to the provider?
Reports a headache as 6 on a 0 to 10 pain scale
Petechiae on the lower extremities
Nuchal rigidity
Positive Kernig's sign - answer-Petechiae on the lower extremities
A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations
should the nurse report to the provider?
Blood pressure 90/50 mm Hg
Respiratory rate 45/min
Weight 14.5 kg (32lbs)
Heart rate 110/min - answer-Respiratory rate 45/min
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of
the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28%
, Hemoglobin 13.5 g/dL
WBC count 8,000
Platelets 250,000 - answer-Hematocrit 28%
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI)
and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in
the plan?
Administer ibuprofen to the child for a temperature greater than 38° C (100.4° F).
Assess the child's blood pressure every 8hr.
Weigh the child weekly at a various times of the day.
Initiate seizure precautions for the child. - answer-Initiate seizure precautions for the child.
A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify
that which of the following findings is an indication of early septic shock?
Blood pressure 30/90 mm Hg
Heart Rate 60/min
Temp 39.1° C (102.4° F) Urinary output 100ml/hr - answer-Temp 39.1° C (102.4°F)
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions
should the nurse implement for a infection control?
Have a designated stethoscope in the infant's room.
Place the infant in a room equipped with negative airflow.
Administer palivizumab as prescribed for the infant.
Remove gloves after leaving the infant's room. - answer-Have a designated stethoscope in the infant's
room.