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Pediatrics Nursing (NRNP 6541) Final Exam
1. Which of the following nursing interventions is the highest priority before
administering a scheduled medication?
A) Documenting the medication administration in the electronic medical record
B) Verifying the patient's identity using two unique identifiers
C) Checking the patient's fluid restriction parameters for the shift
D) Reviewing the patient's discharge plan and home medication list
Rationale: Verifying patient identity using two unique identifiers (like name and date
of birth) prevents critical medication errors and ensures patient safety before any
drug is given.
2. A nurse is caring for a patient on contact precautions for C. difficile. Which hand
hygiene method is mandatory?
A) Applying alcohol-based hand rub until completely dry
B) Washing hands thoroughly with soap and water
C) Rinsing hands with warm sterile water only
D) Wiping hands with an antimicrobial chlorhexidine wipe
Rationale: C. difficile forms hardy spores that are highly resistant to alcohol. Physical
removal via mechanical scrubbing with soap and water is required to eliminate them.
3. Which phase of the nursing process involves comparing the patient's current health
status against established goals?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Rationale: Evaluation is the phase where the nurse measures the patient's response
to interventions and determines if the expected outcomes and goals have been met.
4. A patient is at high risk for developing pressure injuries. How frequently should the
nurse reposition the patient in bed?
A) Every 1 hour
B) Every 2 hours
C) Every 4 hours
D) Every 8 hours
Rationale: Turning and repositioning a bed-bound patient at least every 2 hours
relieves prolonged pressure over bony prominences, preserving tissue perfusion and
preventing skin breakdown.
5. What is the priority nursing action when a patient's peripheral intravenous site
becomes red, warm, and swollen?
A) Slowing the infusion rate to a keep-vein-open speed
B) Applying a cold compress directly over the site immediately
C) Discontinuing the intravenous infusion and removing the catheter
D) Flushing the catheter with normal saline to check patency
Rationale: Redness, warmth, and swelling indicate phlebitis or localized infection.
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The priority action is to stop the infusion and remove the device to prevent further
tissue injury.
6. A nurse is preparing to perform a sterile wound dressing change. Which action
breaks sterile technique?
A) Opening the sterile pack away from the body first
B) Keeping sterile gloved hands above waist level
C) Reaching across the established sterile field to grab a supply
D) Maintaining a one-inch border around the sterile drape
Rationale: Reaching across a sterile field introduces microorganisms from the
nurse's non-sterile clothing and arms, completely contaminating the sterile area.
7. Which vital sign should the nurse assess immediately before administering a dose of
digoxin?
A) Apical pulse rate for one full minute
B) Radial pulse rate for fifteen seconds
C) Systolic and diastolic blood pressure
D) Axillary temperature and respiratory rate
Rationale: Digoxin slows the heart rate. The nurse must assess the apical pulse for
one full minute and hold the medication if the heart rate is below the safe threshold
(typically 60 bpm).
8. A patient is admitted with suspected airborne tuberculosis. Which personal protective
equipment must the nurse wear?
A) Standard surgical mask and clean exam gloves
B) Fluid-resistant gown and a full face shield
C) A fitted N95 respirator or HEPA respirator mask
D) Sterile gloves and a protective surgical cap
Rationale: Airborne precautions require an N95 respirator to filter out microscopic
airborne nuclei that remain suspended in the air when the patient coughs or
breathes.
9. What term describes a professional nurse's legal obligation to provide care up to the
established standard?
A) Autonomy
B) Beneficence
C) Duty
Rationale: Duty is the legal obligation or relationship requiring a clinician to perform
care according to the accepted standards of professional practice.
10. A nurse notes a patient's respiratory rate is 8 breaths per minute. Which medical
term accurately describes this finding?
A) Tachypnea
B) Bradypnea
C) Eupnea
D) Apnea
Rationale: Bradypnea is defined as an abnormally slow respiratory rate, typically
below 12 breaths per minute in a resting adult patient.
11. Which body site is considered the most accurate for measuring core body
temperature?
A) Axillary
B) Temporal
C) Oral
D) Rectal
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Rationale: Rectal temperature readings are highly accurate measurements of core
body temperature because the rectum is a closed cavity with a rich blood supply.
12. A nurse is teaching a patient how to use an incentive spirometer. What instruction
should the nurse include?
A) Exhale forcefully and quickly directly into the mouthpiece
B) Inhale slowly and deeply through the mouthpiece
C) Hold your breath for thirty seconds after exhaling
D) Cough vigorously before placing the device in your mouth
Rationale: An incentive spirometer is designed to encourage deep, slow inspirations
to maximize lung expansion, open collapsed alveoli, and prevent atelectasis.
13. Which of the following is a subjective data finding?
A) Blood pressure reading of 142/88 mmHg
B) The patient stating, "I feel incredibly dizzy right now."
C) A localized rash noted on the patient's right forearm
D) A serum potassium level reported as 3.2 mEq/L
Rationale: Subjective data represents the patient's personal perceptions, feelings, or
statements, which cannot be directly verified or measured by an outside observer.
14. What is the most effective nursing action to maintain skin integrity in an immobile,
incontinent patient?
A) Applying a heavy layer of scented talcum powder to the skin
B) Scrubbing the perineal skin vigorously with hot soapy water
C) Cleansing the skin immediately and applying a moisture barrier
D) Limiting fluid intake to decrease the frequency of urination
Rationale: Prompt cleansing removes corrosive digestive enzymes and moisture,
while a barrier ointment protects the epidermis from breakdown caused by chemical
irritation.
15. A nurse checks a residual volume of 300 mL before a scheduled tube feeding. What
is the priority action?
A) Instill the next scheduled feeding as ordered by the provider
B) Flush the feeding tube with 100 mL of warm water
C) Hold the scheduled feeding and notify the healthcare provider
D) Turn the patient onto their right side and elevate the feet
Rationale: A high gastric residual volume (typically over 250-500 mL depending on
facility protocol) indicates delayed gastric emptying, placing the patient at high risk
for aspiration.
16. Which position is most appropriate for a patient experiencing acute shortness of
breath?
A) Supine position
B) Trendelenburg position
C) Prone position
D) High Fowler's position
Rationale: High Fowler's position (elevating the head of the bed to 60-90 degrees)
lowers the diaphragm, allowing maximum chest expansion and improving
oxygenation.
17. A nurse is preparing to give a subcutaneous injection. What angle of insertion is
typically used for a normal-weight patient?
A) 15 degrees
B) 45 to 90 degrees
C) 90 degrees only
D) 10 to 15 degrees
, 2|Page
Pediatrics Nursing (NRNP 6541) Final Exam
1. Which of the following nursing interventions is the highest priority before
administering a scheduled medication?
A) Documenting the medication administration in the electronic medical record
B) Verifying the patient's identity using two unique identifiers
C) Checking the patient's fluid restriction parameters for the shift
D) Reviewing the patient's discharge plan and home medication list
Rationale: Verifying patient identity using two unique identifiers (like name and date
of birth) prevents critical medication errors and ensures patient safety before any
drug is given.
2. A nurse is caring for a patient on contact precautions for C. difficile. Which hand
hygiene method is mandatory?
A) Applying alcohol-based hand rub until completely dry
B) Washing hands thoroughly with soap and water
C) Rinsing hands with warm sterile water only
D) Wiping hands with an antimicrobial chlorhexidine wipe
Rationale: C. difficile forms hardy spores that are highly resistant to alcohol. Physical
removal via mechanical scrubbing with soap and water is required to eliminate them.
3. Which phase of the nursing process involves comparing the patient's current health
status against established goals?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Rationale: Evaluation is the phase where the nurse measures the patient's response
to interventions and determines if the expected outcomes and goals have been met.
4. A patient is at high risk for developing pressure injuries. How frequently should the
nurse reposition the patient in bed?
A) Every 1 hour
B) Every 2 hours
C) Every 4 hours
D) Every 8 hours
Rationale: Turning and repositioning a bed-bound patient at least every 2 hours
relieves prolonged pressure over bony prominences, preserving tissue perfusion and
preventing skin breakdown.
5. What is the priority nursing action when a patient's peripheral intravenous site
becomes red, warm, and swollen?
A) Slowing the infusion rate to a keep-vein-open speed
B) Applying a cold compress directly over the site immediately
C) Discontinuing the intravenous infusion and removing the catheter
D) Flushing the catheter with normal saline to check patency
Rationale: Redness, warmth, and swelling indicate phlebitis or localized infection.
, 3|Page
The priority action is to stop the infusion and remove the device to prevent further
tissue injury.
6. A nurse is preparing to perform a sterile wound dressing change. Which action
breaks sterile technique?
A) Opening the sterile pack away from the body first
B) Keeping sterile gloved hands above waist level
C) Reaching across the established sterile field to grab a supply
D) Maintaining a one-inch border around the sterile drape
Rationale: Reaching across a sterile field introduces microorganisms from the
nurse's non-sterile clothing and arms, completely contaminating the sterile area.
7. Which vital sign should the nurse assess immediately before administering a dose of
digoxin?
A) Apical pulse rate for one full minute
B) Radial pulse rate for fifteen seconds
C) Systolic and diastolic blood pressure
D) Axillary temperature and respiratory rate
Rationale: Digoxin slows the heart rate. The nurse must assess the apical pulse for
one full minute and hold the medication if the heart rate is below the safe threshold
(typically 60 bpm).
8. A patient is admitted with suspected airborne tuberculosis. Which personal protective
equipment must the nurse wear?
A) Standard surgical mask and clean exam gloves
B) Fluid-resistant gown and a full face shield
C) A fitted N95 respirator or HEPA respirator mask
D) Sterile gloves and a protective surgical cap
Rationale: Airborne precautions require an N95 respirator to filter out microscopic
airborne nuclei that remain suspended in the air when the patient coughs or
breathes.
9. What term describes a professional nurse's legal obligation to provide care up to the
established standard?
A) Autonomy
B) Beneficence
C) Duty
Rationale: Duty is the legal obligation or relationship requiring a clinician to perform
care according to the accepted standards of professional practice.
10. A nurse notes a patient's respiratory rate is 8 breaths per minute. Which medical
term accurately describes this finding?
A) Tachypnea
B) Bradypnea
C) Eupnea
D) Apnea
Rationale: Bradypnea is defined as an abnormally slow respiratory rate, typically
below 12 breaths per minute in a resting adult patient.
11. Which body site is considered the most accurate for measuring core body
temperature?
A) Axillary
B) Temporal
C) Oral
D) Rectal
, 4|Page
Rationale: Rectal temperature readings are highly accurate measurements of core
body temperature because the rectum is a closed cavity with a rich blood supply.
12. A nurse is teaching a patient how to use an incentive spirometer. What instruction
should the nurse include?
A) Exhale forcefully and quickly directly into the mouthpiece
B) Inhale slowly and deeply through the mouthpiece
C) Hold your breath for thirty seconds after exhaling
D) Cough vigorously before placing the device in your mouth
Rationale: An incentive spirometer is designed to encourage deep, slow inspirations
to maximize lung expansion, open collapsed alveoli, and prevent atelectasis.
13. Which of the following is a subjective data finding?
A) Blood pressure reading of 142/88 mmHg
B) The patient stating, "I feel incredibly dizzy right now."
C) A localized rash noted on the patient's right forearm
D) A serum potassium level reported as 3.2 mEq/L
Rationale: Subjective data represents the patient's personal perceptions, feelings, or
statements, which cannot be directly verified or measured by an outside observer.
14. What is the most effective nursing action to maintain skin integrity in an immobile,
incontinent patient?
A) Applying a heavy layer of scented talcum powder to the skin
B) Scrubbing the perineal skin vigorously with hot soapy water
C) Cleansing the skin immediately and applying a moisture barrier
D) Limiting fluid intake to decrease the frequency of urination
Rationale: Prompt cleansing removes corrosive digestive enzymes and moisture,
while a barrier ointment protects the epidermis from breakdown caused by chemical
irritation.
15. A nurse checks a residual volume of 300 mL before a scheduled tube feeding. What
is the priority action?
A) Instill the next scheduled feeding as ordered by the provider
B) Flush the feeding tube with 100 mL of warm water
C) Hold the scheduled feeding and notify the healthcare provider
D) Turn the patient onto their right side and elevate the feet
Rationale: A high gastric residual volume (typically over 250-500 mL depending on
facility protocol) indicates delayed gastric emptying, placing the patient at high risk
for aspiration.
16. Which position is most appropriate for a patient experiencing acute shortness of
breath?
A) Supine position
B) Trendelenburg position
C) Prone position
D) High Fowler's position
Rationale: High Fowler's position (elevating the head of the bed to 60-90 degrees)
lowers the diaphragm, allowing maximum chest expansion and improving
oxygenation.
17. A nurse is preparing to give a subcutaneous injection. What angle of insertion is
typically used for a normal-weight patient?
A) 15 degrees
B) 45 to 90 degrees
C) 90 degrees only
D) 10 to 15 degrees
