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Question 1
A 6-month-old infant is diagnosed with bronchiolitis caused by Respiratory
Syncytial Virus (RSV). Which of the following nursing interventions is the
priority?
A) Administer antibiotics as prescribed.
B) Encourage increased oral fluid intake.
C) Suction nasal secretions and maintain airway patency.
D) Place the infant in a prone position to sleep.
E) Provide antipyretics for fever management.
Correct Answer: C) Suction nasal secretions and maintain airway
patency.
Rationale: Bronchiolitis, especially from RSV, causes copious nasal
secretions that can obstruct the infant's small airways, making
airway clearance the priority for respiratory support.
Question 2
A 4-year-old child is admitted with acute glomerulonephritis. Which of the
following assessment findings would the nurse expect?
A) Hypotension and polyuria.
B) Periorbital edema and dark, tea-colored urine.
C) Weight loss and hyperglycemia.
D) Clear urine and increased appetite.
E) Jaundice and clay-colored stools.
Correct Answer: B) Periorbital edema and dark, tea-colored urine.
Rationale: Acute glomerulonephritis often presents with impaired
kidney function leading to fluid retention (edema, particularly
periorbital) and hematuria (blood in urine), causing it to appear
dark or tea-colored.
,Question 3
A 9-month-old infant is scheduled for a cleft lip repair. Which of the following
interventions is the priority in the immediate postoperative period?
A) Encourage pacifier use for comfort.
B) Position the infant on their back or side to prevent injury to the suture line.
C) Offer a bottle with a regular nipple.
D) Place the infant in a prone position for drainage.
E) Apply petroleum jelly to the suture line.
Correct Answer: B) Position the infant on their back or side to prevent
injury to the suture line.
Rationale: Preventing any tension or trauma to the delicate suture
line is crucial for optimal healing after cleft lip repair. Positioning on
the back or side avoids direct pressure.
Question 4
A nurse is caring for a 2-year-old child admitted with a fever, rash, and
strawberry tongue, eventually diagnosed with Kawasaki Disease. Which of
the following is the most serious potential complication to monitor for?
A) Renal failure.
B) Cardiac arrhythmias.
C) Coronary artery aneurysms.
D) Peripheral neuropathy.
E) Gastrointestinal bleeding.
Correct Answer: C) Coronary artery aneurysms.
Rationale: Kawasaki Disease is an acute systemic vasculitis. The most
critical complication is the development of coronary artery
aneurysms, which can lead to myocardial infarction, sudden death,
or long-term cardiac issues.
Question 5
A 10-year-old child is diagnosed with Type 1 Diabetes Mellitus. Which of the
following statements by the child indicates a need for further teaching?
,A) "I will check my blood sugar before meals and at bedtime."
B) "I can eat whatever I want as long as I take enough insulin."
C) "I should carry a snack with me in case my blood sugar drops."
D) "I need to give myself insulin injections every day."
E) "Exercise helps lower my blood sugar."
Correct Answer: B) "I can eat whatever I want as long as I take enough
insulin."
Rationale: While insulin doses are adjusted for carbohydrate intake,
clients with Type 1 Diabetes still need to adhere to a healthy,
balanced meal plan to maintain optimal glycemic control and overall
health.
Question 6
A nurse is preparing to administer an intramuscular (IM) injection to a 6-
month-old infant. Which of the following sites is the most appropriate?
A) Deltoid muscle.
B) Ventrogluteal muscle.
C) Dorsogluteal muscle.
D) Vastus lateralis muscle.
E) Rectus femoris muscle.
Correct Answer: D) Vastus lateralis muscle.
Rationale: The vastus lateralis muscle (outer thigh) is the preferred
site for IM injections in infants and young children due to its large
size and distance from major nerves and blood vessels.
Question 7
A 3-year-old child with a history of recurrent ear infections presents with ear
pain and a bulging, red tympanic membrane. What is the most likely
diagnosis?
A) Otitis externa.
B) Serous otitis media.
C) Acute otitis media (AOM).
, D) Mastoiditis.
E) Cholesteatoma.
Correct Answer: C) Acute otitis media (AOM).
Rationale: A bulging, erythematous (red) tympanic membrane is a
classic sign of inflammation and fluid accumulation behind the
eardrum, indicative of acute otitis media.
Question 8
A nurse is caring for an infant diagnosed with pyloric stenosis. Which of the
following symptoms would the nurse expect to find?
A) Diarrhea and weight gain.
B) Bilious vomiting.
C) Projectile, non-bilious vomiting after feeding.
D) Jaundice.
E) Abdominal distention.
Correct Answer: C) Projectile, non-bilious vomiting after feeding.
Rationale: Pyloric stenosis is characterized by hypertrophy of the
pyloric muscle, causing an obstruction. This leads to forceful
(projectile) vomiting of stomach contents that have not been mixed
with bile (non-bilious).
Question 9
A child with cystic fibrosis is prescribed pancreatic enzymes. When should
the nurse instruct the parents to administer these enzymes?
A) Once daily in the morning.
B) With meals and snacks.
C) Only when the child has abdominal pain.
D) Before bedtime.
E) Only with high-fat foods.
Correct Answer: B) With meals and snacks.
Rationale: Pancreatic enzymes are taken with all meals and snacks to