Question 1:
A 4-year-old child is admitted with acute lymphoblastic leukemia (ALL). Which of the following
nursing interventions is most appropriate?
A. Administering IV fluids rapidly
B. Implementing protective isolation
C. Encouraging a high-protein diet
D. Providing age-appropriate toys
Answer: B. Implementing protective isolation
Rationale: Children with ALL are at a high risk for infection due to their compromised immune
system. Protective isolation helps prevent the child from being exposed to potentially harmful
pathogens.
Question 2:
A nurse is caring for an infant with severe dehydration. Which of the following findings is most
indicative of severe dehydration?
A. Mild thirst
B. Increased urine output
C. Sunken fontanelles
D. Moist mucous membranes
Answer: C. Sunken fontanelles
Rationale: Sunken fontanelles are a classic sign of severe dehydration in infants, indicating
significant fluid loss and decreased tissue turgor.
Question 3:
A nurse is teaching the parents of a toddler who has iron-deficiency anemia about dietary
modifications. Which of the following foods should the nurse recommend to increase the child's
iron intake?
A. Whole milk
B. Apple slices
,C. Fortified cereals
D. Carrot sticks
Answer: C. Fortified cereals
Rationale: Fortified cereals are a good source of iron and can help increase the child's iron intake,
which is essential in managing iron-deficiency anemia.
Question 4:
A school-age child with asthma is prescribed a peak flow meter. Which of the following actions
should the nurse include in the teaching?
A. Use the peak flow meter before administering inhaled medication
B. Take a deep breath and blow out slowly into the meter
C. Perform the test while sitting in a chair
D. Record the highest of three readings
Answer: D. Record the highest of three readings
Rationale: The child should record the highest of three readings to get the most accurate
measurement of their peak expiratory flow rate.
Question 5:
A nurse is assessing a 10-month-old infant during a well-baby visit. Which of the following
findings should the nurse report to the provider?
A. The infant is able to sit unsupported
B. The infant has a negative Babinski reflex
C. The infant is unable to pull to a standing position
D. The infant has a pincer grasp
Answer: C. The infant is unable to pull to a standing position
Rationale: By 10 months, infants should typically be able to pull to a standing position. Inability to
do so may indicate developmental delays.
,Question 6:
A 3-year-old child is brought to the emergency department with a high fever and difficulty
swallowing. Which of the following is the nurse's priority action?
A. Administer an antipyretic
B. Obtain a throat culture
C. Start an IV line
D. Ensure the child has a patent airway
Answer: D. Ensure the child has a patent airway
Rationale: Airway management is the priority in a child with difficulty swallowing and high fever,
as these symptoms may indicate epiglottitis or another condition that can rapidly compromise the
airway.
Question 7:
A nurse is caring for a child who has nephrotic syndrome. Which of the following findings should
the nurse expect?
A. Hyperalbuminemia
B. Hypertension
C. Edema
D. Hematuria
Answer: C. Edema
Rationale: Edema is a classic symptom of nephrotic syndrome due to the loss of protein in the
urine, leading to decreased oncotic pressure and fluid retention in tissues.
Question 8:
A nurse is providing discharge teaching to the parents of a child who had a tonsillectomy. Which of
the following instructions should the nurse include?
A. Give your child ice cream to soothe the throat
B. Avoid giving your child red-colored liquids
, C. Administer aspirin for pain relief
D. Encourage your child to cough and clear the throat
Answer: B. Avoid giving your child red-colored liquids
Rationale: Red-colored liquids should be avoided after a tonsillectomy because they can be
mistaken for blood if vomiting occurs.
Question 9:
A nurse is planning care for a child with Kawasaki disease. Which of the following interventions
should the nurse include?
A. Administering high-dose aspirin
B. Initiating contact precautions
C. Providing frequent oral care
D. Administering antibiotics
Answer: A. Administering high-dose aspirin
Rationale: High-dose aspirin is used to reduce inflammation and prevent blood clot formation in
children with Kawasaki disease.
Question 10:
A nurse is caring for an infant with a cleft palate repair. Which of the following actions should the
nurse take?
A. Place the infant in a prone position
B. Offer a pacifier for comfort
C. Use a bulb syringe to clear the airway
D. Feed the infant with a special nipple
Answer: D. Feed the infant with a special nipple
Rationale: Infants with a cleft palate repair often require a special nipple to facilitate feeding and
reduce the risk of aspiration.
A 4-year-old child is admitted with acute lymphoblastic leukemia (ALL). Which of the following
nursing interventions is most appropriate?
A. Administering IV fluids rapidly
B. Implementing protective isolation
C. Encouraging a high-protein diet
D. Providing age-appropriate toys
Answer: B. Implementing protective isolation
Rationale: Children with ALL are at a high risk for infection due to their compromised immune
system. Protective isolation helps prevent the child from being exposed to potentially harmful
pathogens.
Question 2:
A nurse is caring for an infant with severe dehydration. Which of the following findings is most
indicative of severe dehydration?
A. Mild thirst
B. Increased urine output
C. Sunken fontanelles
D. Moist mucous membranes
Answer: C. Sunken fontanelles
Rationale: Sunken fontanelles are a classic sign of severe dehydration in infants, indicating
significant fluid loss and decreased tissue turgor.
Question 3:
A nurse is teaching the parents of a toddler who has iron-deficiency anemia about dietary
modifications. Which of the following foods should the nurse recommend to increase the child's
iron intake?
A. Whole milk
B. Apple slices
,C. Fortified cereals
D. Carrot sticks
Answer: C. Fortified cereals
Rationale: Fortified cereals are a good source of iron and can help increase the child's iron intake,
which is essential in managing iron-deficiency anemia.
Question 4:
A school-age child with asthma is prescribed a peak flow meter. Which of the following actions
should the nurse include in the teaching?
A. Use the peak flow meter before administering inhaled medication
B. Take a deep breath and blow out slowly into the meter
C. Perform the test while sitting in a chair
D. Record the highest of three readings
Answer: D. Record the highest of three readings
Rationale: The child should record the highest of three readings to get the most accurate
measurement of their peak expiratory flow rate.
Question 5:
A nurse is assessing a 10-month-old infant during a well-baby visit. Which of the following
findings should the nurse report to the provider?
A. The infant is able to sit unsupported
B. The infant has a negative Babinski reflex
C. The infant is unable to pull to a standing position
D. The infant has a pincer grasp
Answer: C. The infant is unable to pull to a standing position
Rationale: By 10 months, infants should typically be able to pull to a standing position. Inability to
do so may indicate developmental delays.
,Question 6:
A 3-year-old child is brought to the emergency department with a high fever and difficulty
swallowing. Which of the following is the nurse's priority action?
A. Administer an antipyretic
B. Obtain a throat culture
C. Start an IV line
D. Ensure the child has a patent airway
Answer: D. Ensure the child has a patent airway
Rationale: Airway management is the priority in a child with difficulty swallowing and high fever,
as these symptoms may indicate epiglottitis or another condition that can rapidly compromise the
airway.
Question 7:
A nurse is caring for a child who has nephrotic syndrome. Which of the following findings should
the nurse expect?
A. Hyperalbuminemia
B. Hypertension
C. Edema
D. Hematuria
Answer: C. Edema
Rationale: Edema is a classic symptom of nephrotic syndrome due to the loss of protein in the
urine, leading to decreased oncotic pressure and fluid retention in tissues.
Question 8:
A nurse is providing discharge teaching to the parents of a child who had a tonsillectomy. Which of
the following instructions should the nurse include?
A. Give your child ice cream to soothe the throat
B. Avoid giving your child red-colored liquids
, C. Administer aspirin for pain relief
D. Encourage your child to cough and clear the throat
Answer: B. Avoid giving your child red-colored liquids
Rationale: Red-colored liquids should be avoided after a tonsillectomy because they can be
mistaken for blood if vomiting occurs.
Question 9:
A nurse is planning care for a child with Kawasaki disease. Which of the following interventions
should the nurse include?
A. Administering high-dose aspirin
B. Initiating contact precautions
C. Providing frequent oral care
D. Administering antibiotics
Answer: A. Administering high-dose aspirin
Rationale: High-dose aspirin is used to reduce inflammation and prevent blood clot formation in
children with Kawasaki disease.
Question 10:
A nurse is caring for an infant with a cleft palate repair. Which of the following actions should the
nurse take?
A. Place the infant in a prone position
B. Offer a pacifier for comfort
C. Use a bulb syringe to clear the airway
D. Feed the infant with a special nipple
Answer: D. Feed the infant with a special nipple
Rationale: Infants with a cleft palate repair often require a special nipple to facilitate feeding and
reduce the risk of aspiration.
