An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode (“tet” spell).
Which nursing interventions should the nurse implement?
Standard Text: Select all that apply.
1. Administer oxygen.
2. Place the child in knee-chest position.
3. Administer morphine and propranolol intravenously as ordered.
4. Draw blood for a serum hemoglobin.
5. Administer Benadryl as ordered.
A seven-year-old presents to the clinic with an exacerbation of asthma symptoms. On
physical exam, the nurse would expect which of the following findings?
Standard Text: Select all that apply.
1. Increased tactile fremitus
2. Decreased vocal resonance
3. Bronchophony
4. Decreased tactile fremitus
5. Wheezing
A 10-month-old infant has had numerous ear infections since birth. The nurse will
discuss with the parents ways that might reduce the incidence of otitis media and will
include which strategies?
Standard Text: Select all that apply.
1. Prohibiting tobacco smoke in the home
2. Avoiding use of a pacifier while the child is sleeping
3. Breastfeeding the infant
4. Cleaning the child’s ears nightly with peroxide
5. Avoiding use of wood-burning stoves
A child with autism is being admitted to the hospital with dehydration. Upon admission,
the nurse should:
1. Encourage the parents to avoid bringing favorite toys from home that might be lost.
2. Take the child on a tour of the pediatric unit.
3. Assign the child to his single-bed hospital room.
4. Take the child to the playroom for arts and crafts.
The physician has ordered the toddler to receive an oral medication. The toddler has
fought medication administration in the past. Strategies the nurse will use to administer
the medication would include:
Standard Text: Select all that apply.
1. Request the medication in liquid form and draw the medication in an oral syringe.
2. Put the medication in a favorite drink in the child’s sippy cup.
3. Allow the mother to administer the medication to the child.
4. Notify the physician to change the route to intravenous.
5. Hold the child down and squirt the medication in the corner of his mouth.
The clinic nurse is checking the potency of the vaccine. Which finding may have
rendered the vaccine ineffective?
1. The vaccine was frozen as labeled.
2. The vaccines have been stored in a refrigerator where the temperature has been
maintained between 35 to 46F.
3. The vaccine’s expiration date expires within the next month.
4. The vaccine is stored in the door of the refrigerator.
A nurse who is the manager of an ambulatory pediatric health care center is planning
protocols for the routine health care visits of the children. Children within the
catchment area of this care center have a high incidence of obesity. The most important
assessment data in monitoring the two-year-old child with obesity is:
1. Weight alone.
2. The child’s percentile score of height and weight and weight on the growth chart.
3. Changes in the child’s percentile on the growth chart from birth to the present.
4. The child’s body mass index.
A child who has not had a tetanus immunization steps on a rusty nail. The child needs
immediate protection from tetanus. Which of the following should be given to the child
at this time?
1. Toxoid
2. Antigen
3. Killed virus
4. Passive immunity
A four-year-old is seen in the clinic for a sore throat. In the child’s mind, the most likely
causative agent is that the child:
1. Was exposed to someone else with a sore throat.
2. Yelled at his brother.
3. Did not eat the right foods.
4. Did not take his vitamins.
The nurse can instruct parents to expect children in which age group to begin to assume
more independent responsibility for their own management of a chronic condition, such
as blood glucose monitoring, insulin administration, intermittent self-catheterization,
and appropriate inhaler use?
1. Preschoolers
2. School-age children
3. Adolescents
4. Toddlers
The school nurse has noticed an increase in the number of children in the school being
diagnosed with type 2 diabetes. Which changes could the nurse implement at school to
help reduce students’ risk for developing type 2 diabetes?
Standard Text: Select all that apply.
1. Increase the amount of daily physical activity.
2. Meet with all parents and explain the risk that is associated with obesity.
3. Test each child’s urine monthly.
4. Teach the parents to avoid administering aspirin to their children.
5. Work with the cafeteria to decrease the amount of fat in the foods served.
While the nurse is bathing a seven-year-old child, the child states, “I get so sad when
my mom leaves.” The response that ignores the importance of the child’s feelings is:
1. “I am working tonight so I will be with you tonight while your mother is away.”
2. “Could you explain to me what you mean by sad?”
3. “Your mother has to take care of your brothers and sisters, too. She will be back
tomorrow.”
4. “Can you tell me more about how it makes you feel when your mom leaves?”
The nurse in the genetics clinic is working with families undergoing testing for genetic
disease. If the initial testing is positive, more extensive testing is required to confirm:
1. Prenatal diagnostic testing.
2. Carrier screening.
3. Newborn screening.
4. Pre-implantation genetic diagnosis.
While at recess, a child falls and hurts his arm. The school nurse is called and suspects a
fractured arm. The nurse will apply a splint before transporting the child to the hospital.
The nurse will ensure that:
1. The splint is applied firmly enough to prevent swelling.
2. The arm is fully extended in the splint.
3. The splint is fully padded to prevent skin damage.
4. The joints above and below the suspected fracture are immobilized.
The physician has ordered the postoperative four-year-old child to receive
hydromorphine (Dilaudid) intravenously. The drug book lists a therapeutic range for
Dilaudid to be 0.01 to 0.015 mg/kg/dose every three to four hours. What would be the
maximum therapeutic dose of Dilaudid if the child weighs 30 pounds? Round your
answer to the nearest hundredth.
Standard Text:
A child is being discharged from the hospital on home antibiotic infusions for two more
weeks. The intravenous line is in place, and the medication will be delivered by the
pharmacy and ready to administer on the infusion pump. The home health nurse will
visit once a day, but the family will be responsible for administering the medication.
The home health nurse will want to educate the family on:
Standard Text: Select all that apply.
1. How to initiate an intravenous line.
2. How to operate the infusion pump.
3. The side effects of the medication.
4. Actions to take in case of anaphylaxis.
5. Signs of infection.
A woman gives birth to a stillborn infant. It is the policy of the maternity unit to create a
memory box for parents of a fetal demise. Without parental permission, the nurse
should avoid which intervention?
1. Making a plaster cast of the infant’s foot
2. Placing the blanket the baby was wrapped in into the memory box
3. Making hand- and footprints of the infant
4. Clipping a lock of hair to include in the memory box
A child who has Beta-thalassemia is receiving numerous blood transfusions. The child
is also receiving deferoxamine (Desferal) therapy. The parents ask how the
deferoxamine will help their child. Which is an action of deferoxamine that the nurse
should convey?
1. Stimulates red blood cell production
2. Prevents iron overload
3. Provides vitamin supplementation
4. Prevents blood transfusion reactions
The nurse is teaching parents of the child with sickle-cell disease how to avoid
precipitating factors that can contribute to a sickle-cell crisis. Which are precipitating
factors that could contribute to a sickle-cell crisis?
Standard Text: Select all that apply.
1. Regular exercise
2. Fever
3. Dehydration
4. Altitude
5. Increased fluid intake