Practice Questions with Detailed Rationales &
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,1. A nurse is assessing a 9-month-old infant. Which finding should the nurse
report to the provider?
a. Infant sits without support.
b. Infant crawls on hands and knees.
c. Infant babbles "mama" and "dada."
d. Infant does not turn toward sounds.
Correct Answer: d.
Rationale: By 9 months, an infant should turn toward sounds. Failure to do
so may indicate hearing impairment or developmental delay.
2. A nurse is caring for a toddler with a concussion who has forceful vomiting.
Which action should the nurse take first?
a. Administer acetaminophen.
b. Reassess pain level.
c. Notify the provider immediately.
d. Document the finding.
Correct Answer: c.
Rationale: Forceful vomiting after a head injury can indicate increased
intracranial pressure and requires immediate provider notification.
3. A 9-year-old child has severe facial swelling, wheezing, and hives after
peanut exposure. Which medication should the nurse prepare to administer
first?
a. Albuterol nebulizer.
b. Oral corticosteroid.
c. Intramuscular epinephrine.
, d. Intravenous diphenhydramine.
Correct Answer: c.
Rationale: Intramuscular epinephrine is the first-line treatment for
anaphylaxis.
4. A nurse is caring for a child with dehydration from gastroenteritis. Which
finding indicates severe dehydration?
a. Moist mucous membranes.
b. Capillary refill of 2 seconds.
c. Sunken eyeballs and no tears.
d. Urine output of 1 mL/kg/hr.
Correct Answer: c.
Rationale: Sunken eyes and absent tears are signs of severe dehydration in
children.
5. A child with asthma is experiencing acute wheezing and mild retractions.
Which medication should the nurse administer first?
a. Inhaled albuterol.
b. Oral prednisone.
c. Inhaled fluticasone.
d. Intravenous theophylline.
Correct Answer: a.
Rationale: A short-acting beta-2 agonist such as albuterol provides rapid
bronchodilation during an acute asthma attack.
6. A nurse is caring for a child with croup who has a barking cough and
inspiratory stridor. Which intervention is priority?