ENPC Practice test

ENPC Practice test A preschooler has a small laceration that required 2 stitches. The nurse covers the wound with a bandage knowing that it will comfort the child to have it covered. What is the developmental reason for this intervention. - ANS Preschoolers are magical thinkers and imagine bandages keep their insides from coming out. A 7-month old presents to the ED with a complaint of fever. Assessment reveals a patent airway and a slight cyanosis around his lips and nail beds. He is alert and interactive. His vital signs are 38.5 (101.3), HR 134, RR 32, BP 78/54 mm Hg, and SPO2 of 84%. The nurse notes a healed surgical scar on his chest.Based on this assessment, what is the nurse's priority? - ANS As if the SPO2 is normal for him. An 11-year-old presents to the ED with a complaint of hitting his head while playing soccer. The nurse enters the room and performs an across the room assessment. He is starting at the wall. He has no increased work of breathing and his color is pink. Using the PAT what classification will the nurse assign? - ANS Sicker The pediatric prioritization process components include the focused assessment, focused history, acuity rating decision and: - ANS The pediatric assessment triangle (PAT) A 2-year-old is brought to the ED by her father when he found her face down in the pool. She remains unresponsive and is breathing shallowly and slowly. Her color is pale. What is the priority? - ANS Immobilize the cervical spine A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal alignment, padding should be placed under which area? - ANS The shoulders. Test the Ph of the gastric contents. - ANS The nurse is preparing to administer a feeding through an NG tube. The tube position was verified by radiograph after insertion 2 hours ago. What is the best way to verify placement before feeding? A 20-ml syringe with a stopcock - ANS What is the best method to rapidly administer a 20 ml/kg bolus of 0.9% normal saline to a pediatric patient weighing 8 kg. Use an infusion pump to deliver fluids - ANS Immediately after intraosseous insertion the nurse assesses the infusion and notes that the fluid is not dripping. How should the nurse respond? Croup - ANS A 13-month old presents to the ED with a 2-day history of a low-grade fever, increased work of breathing, and tonight developed a barky cough and inspiratory stridor. What condition does the nurse suspect. in the morning - ANS In providing education to a family regarding obtaining baseline peak airway flow for a child with asthma, the nurse will recommend what time of the day Every 2 to 5 minutes - ANS The nurse is planning to begin oral rehydration therapy for a 9-month old with mild dehydration. She provides the caregivers witha glucose and solution and instructs them to administer small amounts. Pyloric stenosis - ANS Caregivers being in their 3-week-old neonate and describe nonbilous vomiting after each feeding that is becoming more forceful over the past 24 hours.The last time he vomited the vomitus hit a chair 2 feet away. They say he cries, and sucks vigourrously on his pacifier right after vomiting as through still hungry. He is not experiencing any diarrhea. What condition is the most liekly cause of these signs and symptoms. Dry and warm the neonate - ANS A neonate is delivered in the ED and placed on a radiant warmer. There is no staining of the amniotic fluid. What is the first step in neonatal resucitation. A minor who lives with a parent or guardian but legally is able to make health decisions - ANS In dicussing the legal care of the adolescent patient, what is a mature minor? Tell me about a time when you've felt unsafe in your relationship - ANS Which of the following screening statements/questions is most appropirate in asssessing an adolescent for dating violence Blood pressure - ANS Which sign distinguishes compensated shock from decompensated shock in the pediatric patient? Administration of epinephrine - ANS A 5-year-old arrives to the ED unconscious with a heart rate of 32 beats/minute, weak, thready pulses, and pale mottled skin. The team has begun bag-mask ventilation with 100% oxygen and chest compressions with no improvement in the heart rate. An intraosseous line is in place. Which of the following interventions is the priority. 2% - ANS A 19-month old infant pulled himself up onto the hearth of a fireplace. While doing so, he fell forward onto the hot glass doors and sustained deep partial thickness burns to the bilateral palmar aspects f both hands. What is the approximate percentage of total body surface area burned? A pressure dressing to the forehead - ANS An ambulance arrives with a 13-year-old pedestrian hit by a car. Identified injuries reported by paramedics include multiple abrasions to the head and face, a large, actively bleeding laceration to the forehead, hip pain with the leg externally rotated, and bruising across the chest and abdomen. The patient is in full spinal immobilization and has 2 IV catheters and a nonrebreather oxygen mask in place. Vital signs are BP 110/70, HR 118, RR 24, SPO296%. Glasgow coma scale score is 15. What is the priority? Extrapyramidal symptoms - ANS A 15-year-old with a history of schizophrenia is taking risperidone and lithium. She presents with dystonia, akinesia, a shuffling gait, muscle rigidity, and tremors. What does the nurse suspect is the cause of these signs and symptoms? A deep partial thickness sharply demarcated burn on the buttocks of a toddler, reportedly from the child turning on the hot water while in the tub - ANS Which of the following burn injury patterns and history indicates suspected child maltreatment. Skeletal survey - ANS A mother presents to the ER with a 6-week old infant iwth no medical issues after a normal delivery, until yesterday. Mom states that he has been eating properly, vomiting and that hes hard to wake up. The infant is responsive only to painful stimuli. The anterior fontanel is bulging. He is mildly tachycardic, but otherwise vital signs are normal. What diagnostic evaluation will the nurse expect for thhis infant. One who is not sleeping because of dreams of the incident - ANS A malfunctioning oxygen tank explodes near a child's bed in the ED resulting in an extensive burn injury to the child. Four nurses participate in the child's immediate care. Which nurse requires intervention after this critical incident. Yellow - ANS Two ambulances collide in front of the hospital. The victims include 3 pediatric victims. Using the Jumpstart triage system, which category assessment will the nurse give to a 2-year-old who is lying on the groun, alert and crying with spontenous respirations of 36 breaths per minute and present peripheral pulses?