1. In planning care for a 6 month-old infant, what must the nurse provide to assist
in the development of trust Ans: C) Security
2. 2. A nurse has just received a medication order which is not legible. Which
statement best reflects assertive communication Ans: B) "Would you please clarify
what you have written so I am sure I am reading it correctly?"
3. 3. What is the most important consideration when teaching parents how to reduce
risks in the home Ans: D) Age of children in the home
4. 4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as
the nurse enters the room to request something for pain. The nurse should: C)
Administer the prescribed analgesia
5. 5. While caring for a toddler with croup, which initial sign of croup requires the
nurse's immediate attention Ans: A) Respiratory rate of 42
6. 6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On
initial assessment, the nurse would anticipate which of the following assessment
findings Ans: A) Lethargy
7. 7. The emergency room nurse admits a child who experienced a seizure at school.
The father comments that this is the first occurrence, and denies any family history of
,epilepsy. What is the best response by the nurse Ans: B) "The seizure may or may not
mean your child has epilepsy."
8. 8. Alcohol and drug abuse impairs judgment and increases risk taking
behavior. What nursing diagnosis best applies Ans: A) Risk for injury
9. 9. Which these findings would the nurse more closely associate with anemia in a 10
month-old infant Ans: B) Pale mucosa of the eyelids and lips
10. 10. The nurse is caring for a client in hypertensive crisis in an intensive care unit.
The priority assessment in the first hour of care is: D) Pupil responses
11. 11. Which of these clients who are all in the terminal stage of cancer is least
appropriate to suggest the use of patient controlled analgesia (PCA) with a pump Ans
D) A preschooler with intermittent episodes of alertness
12. 12. The nurse is about to assess a 6 month-old child with nonorganic failure-
to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be: D) Pale,
thin arms and legs, uninterested in surroundings
13. 13. As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion Ans: D) Hair loss
14. 14. While caring for a client who was admitted with myocardial infarction (MI) 2
,days ago, the nurse notes today's temperature is 101.1 degrees Fahren- heit (38.5
degrees
, Celsius). The appropriate nursing intervention is to: B) Administer aceta- minophen as
ordered as this is normal at this time
15. 15. A client is admitted for first and second degree burns on the face, neck, anterior
chest and hands. The nurse's priority should be: B) Assess for dyspnea or stridor
16. 16. Which of these clients who call the community health clinic would the nurse
ask to come in that day to be seen by the health care provider Ans: D) I went to the
bathroom and my urine looked very red and it didn't hurt when I went.
17. 17. Which of these parents' comment for a newborn would most likely reveal an
initial finding of a suspected pyloric stenosis Ans: C) Mild vomiting that progressed to
vomiting shooting across the room.
18. 18. The nurse is assessing a child for clinical manifestations of iron de- ficiency
anemia. Which factor would the nurse recognize as cause for the findings Ans: B)
Tissue hypoxia
19. 19. The nurse would expect the cystic fibrosis client to receive supplemen- tal
pancreatic enzymes along with a diet: A) High in carbohydrates and proteins
20. 20. In evaluating the growth of a 12 month-old child, which of these findings would
the nurse expect to be present in the infant Ans: C) Tripled the birth weight
21. 21. A Hispanic client in the postpartum period refuses the hospital food because
it is "cold." The best initial action by the nurse is to: B) Ask the client what foods are