ANSWERS WITH RATIONALE | AGRADE
/. A nurse in the emergency department is caring for a 2-yr old child who was found by
his parents crying and holding a container of toilet bowl cleaner. The child's lips are
edematous and inflamed, and he is drooling. Which of the following is the following
priority action by the nurse?
a. Remove the child's contaminated clothing.
b. Check the child's respiratory status.
c. Administer an antidote to the child.
d. Establish IV access for the child. - Answer-✅b. Check the child's respiratory status.
Rationale: When applying the ABC priority setting framework, airway is always the
highest priority because the airway must be clear and open for oxygen exchange to
occur. Breathing is the second highest priority in the ABC priority setting framework
because adequate ventilatory effort is essential in order for oxygen change to occur.
/.A nurse is teaching a parent of a 12-month old child about development during the
toddler years. Which of the following statements should the nurse include?
a. Your child should be referring to himself using the appropriate pronoun by the 18
months of age
b. a toddler's interest in looking at pictures occurs at 20 months of age
c. a toddler should have daytime control of his bowel and bladder by 24 months of age.
d. your child should be able to scribble spontaneously using a crayon at the age of 15
months - Answer-✅d. your child should be able to scribble spontaneously using a
crayon at the age of 15 months
Rationale: The nurse should teach the parent that at the age of 15 months, the toddler
should be
able to scribble spontaneously, and at the age of 18 months, the toddler should be able
to make
strokes imitatively
/.A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride
100ml IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/ml. The
nurse should set the manual IV infusion to deliver how many gtt/min? (Round the
answer to the nearest whole number) - Answer-✅25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
/.A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the
following actions should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
,c. Explain procedures using medical terminology
d. Stop the assessment if the child becomes uncooperative. - Answer-✅b. Minimize
physical contact with the child initially.
Rationale: The nurse should initially minimize physical contact with the toddler, and then
progress from the least traumatic to the most traumatic procedures.
/.A nurse is caring for an 18-yr old adolescent who is up to date on immunizations and is
planning to attend college. The nurse should inform the client that he should receive
which of the following immunizations prior to moving into a campus dormitory.
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. rotavirus
d. Herpes zoster - Answer-✅b. Meningococcal polysaccharide
Rationale: The meningococcal polysaccharide immunization is used to prevent infection
by
certain groups of meningococcal bacteria. Meningococcal infection can cause life-
threatening
illnesses, such as meningococcal meningitis, which affects the brain, and
meningococcemia,
which affects the blood. Both of these conditions can be fatal. College freshmen,
particularly
those who live in dormitories, are at an increased risk for meningococcal disease
relative to other persons their age. Therefore, the Centers for Disease Control and
Prevention has issued a
recommendation that all incoming college students receive the meningococcal
immunization.
/.A nurse is teaching the parent of an infant about food allergens. Which of the following
foods should the nurse include as being the most common food allergy in children.
a. Cow's milk
b. Wheat bread
c. Corn syrup
d. Eggs - Answer-✅a. Cow's milk
Rationale: According to evidence-based practice, the nurse should instruct the parent
that cow's
milk is the most common food allergy in children. Some children are sensitive to the
protein,
called casein, found in cow's milk. They have difficulty metabolizing the casein and are,
therefore, allergic to cow's milk.
/.A nurse is teaching the parent of a toddler about home safety. Which of the following
statements by the parent indicates an understanding of the teaching?
a. I lock my medications in the medicine cabinet
b. I keep my child's crib mattress at the highest level
c. I turn pot handles to the side of my stove while cooking.
, d. I will give my child syrup of ipecac if she swallows something poisonous. - Answer-
✅a. I lock my medications in the medicine cabinet
Rationale: Locking up medications and other potential poisons prevents access.
Toddlers have
improved gross and fine motor skills that allow for further exploration of the environment
and
possible access to hazardous substances.
/.A nurse is performing a physical assessment on a 6-month old infant. Which of the
following reflexes should the nurse expect to find?
a. Stepping
b. Babinski
c. Extrusion
d. Moro - Answer-✅b. Babinski
Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot and
causing
the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year.
Persistence
of neonatal reflexes might indicate neurological deficits.
/.A nurse is preparing to administer recommended immunizations to a 2-month old
infant. Which of the following immunizations should the nurse plan to administer.
a. Human papilloma virus (HPV) and hepatitis A
b. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis
(TDaP)
c. Haemophilus influenza type B (Hib) and inactivated polio virus (IPV)
d. Varicella (VAR) and live attenuated influenza vaccine (LAIV) - Answer-✅c.
Haemophilus influenza type B (Hib) and inactivated polio virus (IPV)
Rationale: The recommended immunizations for a 2-month-old infant include Hib and
IPV. The
Hib immunization series consists of 3 to 4 doses, depending on the immunization used,
and at a
minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The
IPV
immunization series consists of 4 doses and is administered at the ages of 2 months, 4
months, 6
to 18 months, and 4 to 6 years.
/.A nurse is developing a plan of care for a school-age child who underwent a surgical
procedure that resulted in temporary loss of vision. Which of the following interventions
should the nurse include in the plan of care?
a. Assign an assistive personnel to feed the child.
b. Explain sounds the child is hearing
c. Have the child use a cane when ambulating
d. Rotate nurses caring for the child. - Answer-✅b. Explain sounds the child is hearing