The nurse is caring for four clients in the neonatal intensive care unit. Which infant has
the greatest risk of developing retinopathy of prematurity (ROP)?
1. 28-weeks’-gestation infant who has been on long-term oxygen and weighed 1,400
grams
2. 32-weeks’-gestation infant of African heritage with a congenital heart defect who
needed no oxygen and weighed 1,850 grams
3. 28-weeks’-gestation female infant who was on short-term oxygen, weighed 1,420
grams, and was treated with phototherapy
4. 36-weeks’-gestation, small-for-gestational-age infant who was in an oxyhood for 12
hours and weighed 1,800 grams
A seven-year-old girl has been diagnosed with rheumatic fever. The physician has
talked with the parents and child and explained the disease and the planned medical
treatment. Which statement by the parents needs further clarification?
1. “I understand rheumatic fever is a strep infection of the heart.”
2. “My child will be on bed rest for several weeks.”
3. “My child will be treated with aspirin and/or corticosteroids.”
4. “Once my child has recovered, she will still need to be monitored for sequelae to the
disease.”
The nurse has been working with the parents of a dying child. The nurse has explained
signs of imminent death. Which statement by the parents indicates that they understand
the teaching?
1. “I understand that my child can see me until the very end.”
2. “Dying children always lose consciousness a few hours before they pass.”
3. “My child may become flushed as his heart slows down.”
4. “My child may see visions that I cannot see.”
The nurse explains to new parents that as healthy children are exposed to more
infections, they:
1. Naturally develop antibodies.
2. Are found to be healthier.
3. Will acquire terminal illnesses.
4. Will weaken their immune systems.
A child is undergoing hemodialysis. The child should be monitored closely for:
Standard Text: Select all that apply.
1. Migraines.
2. Hypotension.
3. Infections.
4. Fluid overload.
5. Shock.
While promoting participation in physical activities at school, the nurse recognizes that
factors which may inhibit the adolescent from participating would include:
Standard Text: Select all that apply.
1. The family members do not regularly participate in physical activity.
2. The adolescent is overweight.
3. The public school does not have sports programs available.
4. Participating in sports may require financial resources.
5. Physical activities are limited to the best athletes.
A child is admitted to the PICU following an accident. The parents ask the nurse about
bringing the siblings to visit. The nurse will meet with the siblings and the parents and:
Standard Text: Select all that apply.
1. Describe the sights, sounds, and smells of the pediatric intensive care unit.
2. Provide a simple explanation of the other children being cared for in the PICU.
3. Explain the child’s injuries in ways that are appropriate to the ages of the siblings.
4. Describe how the child looks.
5. Explain why the siblings will not be able to visit until the child has stabilized and is
progressing.
The postoperative unit of the pediatric hospital has several children who had surgery
this morning. While making rounds, the nurse observes all of the following behaviors.
Which child should be further evaluated as to postoperative pain?
1. The six-month-old in deep sleep
2. The two-year-old who is cooperative when the nurse takes his vital signs
3. The four-year-old who is actively watching cartoons
4. The 14-month-old who is thrashing his arms and legs
The nurse is having difficulty coping with the impending death of a child. Which would
most likely be the best resource for the nurse at this time?
1. Co-workers
2. Hospice nurses
3. Unit manager
4. Spouse
Following a car accident, a four-year-old child was admitted to the pediatric intensive
care unit. Both parents were injured in the accident and have been unable to visit. The
child’s condition has stabilized, and the child is transferred to the surgical unit for the
remainder of her hospitalization. The child has not expressed any feelings during the
hospitalization. Which interventions might help the child express her feelings?
1. Asking the hospital chaplain to talk with the child
2. Use play therapy including mother, father, and child dolls.
3. Use journaling to allow the child to express herself.
4. Using humor by telling knock-knock jokes
A child returns from exploratory abdominal surgery following a gunshot wound to the
abdomen. Which nursing intervention would the nurse omit from the plan of care for
this child?
1. NPO status until bowel sounds return
2. Frequent assessment of the surgical site
3. Avoiding narcotics to prevent depression of the respiratory system
4. Allow parents at the bedside as soon as possible.
The hospital unit is very busy and nursing is understaffed. The nurse recognizes that
death is imminent in one of her assigned patients. Nursing behaviors to offer family
support would include:
Standard Text: Select all that apply.
1. Using active listening techniques when in the child’s hospital room.
2. Sitting in the room as time permits and looking the parents in the eye.
3. Avoiding tears in the child’s room.
4. Offering to call and notify family.
5. Recognizing that these parents’ needs are greater than the other patients and staying
with the parents.
A young infant is admitted to the hospital unit with physical injuries. The nurse is
taking the child’s history. The statement by the parent that would be most suspicious for
abuse is:
1. “I was walking up the steps and slipped on the ice, falling while carrying my baby.”
2. “The baby’s 18-month-old brother was trying to pull the baby out of the crib and
dropped the baby on the floor.”
3. “I placed the baby in the infant swing. His six-year-old brother was running through
the house and tripped over the swing, causing it to fall.”
4. “I did not realize that my baby was able to roll over yet, and I was just gone a minute
to check on dinner when the baby rolled off of the couch and onto our tile floor.”
The nurse is working with the mother of a child with autism. The goal of the session is
to plan strategies to increase the child’s socialization. The nurse is explaining behavior
modification as a treatment process. The nurse will encourage the mother to:
1. Create a reward system when the child interacts with a person.
2. Punish the child when the child’s social behaviors are inappropriate.
3. Use dolls to demonstrate appropriate social interactions to the child.
4. Enroll the child in a day care to encourage interaction with other children.
A supervisor is reviewing the documentation of the nurses in the unit. The
documentation that most accurately and correctly contains all the required parts for a
narrative entry is the entry that reads:
1. “1630 catheterized using an 8 French catheter, 45 ml clear yellow urine obtained,
specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in
mother’s arms following catheter removal. M. May RN”
2. “1/9/05 2 p.m. g-tube accessed, positive air gurgle over stomach: 5 ml air injected, 10
ml residual stomach contents returned to stomach, PediaSure formula hung on
Kangaroo pump infusing at 60 ml/hr for 1 hour. Child grunting intermittently
throughout procedure. K. Earnst RN”
3. “Feb. ’05 Portacath assessed with Huber needle. Blood return present. Flushed with
NaCl sol., IV gamma globulins hung and infusing at 30 ml/hr. Child smiling and playful
throughout the procedure. P. Potter, RN”
4. “4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site
cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and
trach ties applied. F. Luck RN”
During the nurse’s initial assessment of a school-age child, the child reports a pain level
of 6 out of 10. The child is lying quietly in bed watching television. The nurse should:
1. Reassess the child in 15 minutes to see if the pain rating has changed.
2. Administer the prescribed analgesic.
3. Do nothing, since the child appears to be resting.
4. Ask the child’s parents if they think the child is hurting.
The nurse is working with the parents of a child with a chronic condition. The nurse
concludes that the parents’ caregiver burden might become overwhelming when the
mother states which of the following?
1. “My mother moved in and helps us with the care of our family.”
2. “I chose to quit my job to be home with my child, and my husband helps in the
evening when he can.”
3. “I have to care for my child day and night, which leaves little time for me.”
4. “Our health insurer sent us a rejection letter for my child’s brand-name medication,
and we must fill out forms to get the generic.”
The role of the registered nurse as a nurse educator is to:
1. Provide primary care for healthy children.
2. Assist the family in making informed decisions by providing information about the
pros and cons of the treatment plan.
3. Assist the primary care nurse with procedures requiring advanced practice skills.
4. Communicate with the hospitalized school-aged child’s classroom teacher to assist
the child in achieving classroom goals.
A parent asks the nurse if there is anything that can be done to reduce pain that his
three-year-old experiences each morning when blood is drawn for lab studies. The most
appropriate method the nurse can suggest to relieve pain associated with the
venipuncture is:
1. Intravenous sedation 15 minutes prior to the procedure.
2. Use of guided imagery during the procedure.
3. EMLA cream (lidocaine 2.5% and prilocaine 2.5%) applied to the skin at least one
hour prior to the procedure.
4. Use of muscle-relaxation techniques.