CORRECT ANSWERS 2025
The nurse is attempting to reduce the risk for impaired skin integrity related to immobility in a toddler.
Which actions does the nurse include in the plan of care? Select all that apply.
-change position frequently
-clean skin only when soiled
-promote good nutrition
The nurse develops the plan of care for a toddler with an acetaminophen overdose. Which intervention
should the nurse expect to include as part of the initial treatment?
gastric lavage
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever.
What would be the best option?
Allow the parent to hold the child and give the medication.
Which family should the nurse determine as most in need of follow-up?
single parent with a toddler who has third-degree burns over 20% of the body
A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes
no sound during the procedure. Which comment by the nurse would be most appropriate?
"It's okay to cry when something hurts."
,A toddler has a temperature above 101°F (38.3°C). The healthcare provider orders acetaminophen, 120
mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to
administer the medication rectally if the child has a diagnosis of
thrombocytopenia
A toddler is in the hospital. The parents tell the nurse they are concerned about the seriousness of the
child's illness. Which response to the parents is most appropriate?
"It must be difficult for you when your child is ill and hospitalized. Tell me your concerns."
When teaching caregiver of a client with congenital heart disease, the nurse should explain all medical
treatments and emphasize which instruction?
"Try to maintain your child's usual lifestyle to promote normal development."
A parent calls the nurse to report that their toddler has just been burned on the arm. What should the
nurse advise the parent to do first?
Run cool water over the burned area, and then wrap it in a clean cloth.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays,
the I.V. tubing becomes disconnected from the catheter. What should the nurse do first?
Clamp the catheter.
, The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an
elevated serum potassium level. What is the priority assessment action for the nurse based on the
laboratory data?
Institute telemetry monitoring.
The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the
nurse revise?
padded tongue blade at the bedside
A young child who has been sexually abused has difficulty putting feelings into words. Which approach
should the nurse employ with the child?
engaging in play therapy
When assessing speech development, the nurse should refer which child for further re-evaluation?
an 18-month-old who only says "no"
Which action should the nurse take when suspecting that a child has been abused by the parent?
Ensure that any and all findings are reported to the proper authorities.
The nurse develops the preoperative teaching plan for a 14-month-old child with an undescended testis
who is scheduled to have surgery. Which method is most appropriate?
Explain to the parents how the defect will be corrected.