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A 5-day-old patient presents with feeding intolerance, lethargy, temperature instability, and
apnea. The nurse has a high suspicion for neonatal sepsis.
An 18-month-old presents to the emergency department with several days of worsening
respiratory distress, persistent cough, thick secretions, and lethargy. The parent states that the
patient was recently diagnosed with respiratory syncytial virus (RSV). The nurse recognizes
these symptoms as consistent with bronchiolitis.
A child with 30% body surface area burns is awaiting transfer to the burn center. The nurse
should cover the burns with dry towel or sheet
A 14-year-old female reports a sudden onset of severe pelvic pain with guarding. Which of the
following is MOST concerning? referred shoulder pain
A 14-year-old female accompanied by a caregiver presents to the emergency department with
complaints of abdominal pain. The nurse notes a tattoo on the abdomen with initials and
,attempts to discuss the tattoo without success. The patient tries to hide the tattoo. The nurse
should be MOST concerned about human trafficking.
A patient with a traumatic head injury presents with signs and symptoms of Cushing's triad.
Which of the following would be an expected finding? irregular, decreased respirations
A 2-month-old presents with difficulty breathing associated with tachypnea, mild retractions,
and copious amounts of nasal drainage. The MOST appropriate intervention is to suction
the nares.
Which of the following is MOST consistent with a diagnosis of tracheoesophageal fistula?
cyanosis with feeding
A 5-day-old neonate is diagnosed with hyperbilirubinemia. If left untreated, the infant may have
long-term issues with intellectual deficits.
Abdominal pain can be a characteristic of which respiratory diagnosis? pneumonia
, Which developmental task is expected in a toddler? autonomy
What is the correct maintenance fluid rate for a 23-kg patient? 65 mL/hr
Maintenance fluid in a 23 kg patient is: 1500 mL + (20 mL/kg for each kg > 20 kg)
A school-age girl presents with a straddle injury sustained on a jungle gym. Findings include
pain, bruising, and a unilateral labial laceration. Definitive treatment is transfer to the
operating room for injury repair.
Which of the following injuries is MOST suggestive of child maltreatment?
circumferential burns to both feet
A 5-year-old presents to the emergency department with a fever for the past 2 days. The patient
is dancing around singing songs. The skin is pink and there is no evidence of respiratory distress.
Utilizing the Pediatric Assessment Triangle (PAT), the nurse would score the patient as
sick.
When using the FLACC scale to assess acute pain in an infant, the nurse would evaluate for
facial grimacing