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answers 2025
After a tonsillectomy and adenoidectomy, which finding should alert the nurse to suspect early hemorrhage in a 5-year-old child? a. drooling of bright red secretions b. pulse rate of 95 bpm c. vomiting of 25 mL of dark brown emesis d. BP of 95/56 mm HG - correct answer ✅Answer: a. drooling of bright red secretions A nurse is teaching the parents of a pre-schooler about the possibility of postoperative hemorrhage after a tonsillectomy and adenoidectomy. When should the nurse explain that the risk of bleeding is the greatest? a. 1-3 days post-op b. 4-6 days post-op c. 7-10 days post-op d. 11-14 days post-op - correct answer ✅Answer: c. 7-10 days post-op Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. a. coughing b. respiratory rate of 35 breaths/min c. heart rate of 95 beats/min d. restlessness
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e. malaise f. diaphoresis - correct answer ✅Answers: a. coughing b. respiratory rate of 35 breaths/min d. restlessness f. diaphoresis A child with cystic fibrosis is receiving gentamicin. Which nursing action is most appropriate? a. monitoring intake and output b. obtaining daily weights c. monitoring the client for indications of constipation d. obtaining stool samples for hemoccult testing - correct answer ✅Answer: a. monitoring intake and output What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis? a. low-protein diet b. high-fat diet c. low-carbohydrate diet d. high-calorie diet - correct answer ✅Answer: d. high-calorie diet
answers 2025
The parent of a 16-month-old child calls the clinic because the child has a low- grade fever, cold symptoms, and a hoarse cough. What should the nurse suggest that the parent do? a. offer extra fluids frequently b. bring the child to the clinic immediately c. count the child's respiratory rate d. use a hot air vaporizer - correct answer ✅Answer: a. offer extra fluids frequently A child has viral pharyngitis. What should the nurse advise the parents to do? Select all that apply. a. use a cool mist vaporizer b. offer a soft-to-liquid diet c. administer amoxicillin d. administer acetaminophen e. place the child on secretion precautions - correct answer ✅Answer: a. use a cool mist vaporizer b. offer a soft-to-liquid diet d. administer acetaminophen An infant is being treated at home for bronchiolitis. What should the nurse teach the parent about home care? Select all that apply.
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a. offering small amounts of fluids frequently b. allowing the infant to sleep prone c. calling the clinic if the infant vomits d. writing down how much the infant drinks e. performing chest physiotherapy every 4 hours f. watching for difficulty breathing - correct answer ✅Answer: a. offering small amounts of fluids frequently f. watching for difficulty breathing A teaching care plan to prevent transmission of respiratory syncytial virus (RSV) should include what information? Select all that apply. a. the virus can be spread by direct contact b. the virus can be spread by indirect contact c. palivizumab is recommended to prevent RSV for all toddlers in daycare d. the virus is typically contagious for 3 weeks e. older children seldom spread RSV f. frequent hand-washing helps reduce the spread of RSV - correct answer ✅Answer: a. the virus can be spread by direct contact b. the virus can be spread by indirect contact f. frequent hand-washing helps reduce the spread of RSV
answers 2025
A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client? a. high-fat, high-carbohydrate b. high-calorie, high-protein c. high-calorie, high-carbohydrate d. high-carbohydrate, high-protein - correct answer ✅Answer: b. high-calorie, high-protein Rationale: necessary to ensure adequate growth The nurse is caring for a 7-year-old who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should FIRST: a. assess the vital signs b. reinforce the dressing c. apply pressure just above the catheter insertion site d. notify the healthcare provider - correct answer ✅Answer: c. apply pressure just above the catheter insertion site A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family, the nurse should: a. advise the family to bring the child to the hospital for a tour a week in advance
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b. explain that the child will need a large bandage after the procedure c. discourage bringing favorite toys that might become associated with pain d. explain that the child may get up as soon as the vital signs are stable - correct answer ✅Answer: b. explain that the child will need a large bandage after the procedure When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which technique? a. ultra-high-frequency sound waves b. catheter placed in the right femoral vein c. cutdown procedure to place a catheter d. general anesthesia - correct answer ✅Answer: b. catheter placed in the right femoral vein Rationale: in children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which information should the nurse expect to include? a. restriction of the child's activities for the next 3 weeks b. use of sponge baths until the stitches are removed c. use of prophylactic antibiotics before receiving any dental work
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d. if the child vomits within 15 minutes of administration, the dosage should be repeated - correct answer ✅Answer: a. digoxin enable the heart to pump more effectively with a slower and more regular rhythm Which signs and symptoms would lead the nurse to suspect a child has Tetralogy of Fallot? Select all that apply. a. murmur b. history of squatting c. bounding pulses d. cyanosis e. faint pulse f. tachypnea - correct answer ✅Answer: a. murmur b. history of squatting d. cyanosis f. tachypnea The nurse is caring for a newborn with a large ventricular septal defect. The client has undergone pulmonary artery banding. Which assessment findings indicate that the pulmonary artery band is functioning effectively? a. capillary refill is less than 3 seconds b. urine output is greater than 1 mL/kg/hr
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c. breath sounds are clear and equal bilaterally d. radial pulses are bounding - correct answer ✅Answer: c. breath sounds are clear and equal bilaterally Rationale: Pulmonary artery banding is a palliative treatment used in pediatric clients with congenital cardiac defects with increased pulmonary blood flow. The pulmonary artery band reduces excessive pulmonary blood flow and protects the lungs from irreversible damage. A child with Tetralogy of Fallot becomes upset, cries, and thrashes around when a blood specimen is obtained. The child becomes cyanotic, and the respiratory rate increases to 44 breaths/min. Which action should the nurse do FIRST? a. obtain a prescription for sedation for the child b. assess for an irregular heart rate and rhythm c. explain to the child that it will only hurt for a short time d. place the child in a knee-to-chest position - correct answer ✅Answer: d.place the child in a knee-to-chest position Rationale: the child is experiencing a "tet" or cyanotic episode When assessing a child after heart surgery to correct Tetralogy of Fallot, which finding should alert the nurse to suspect a low cardiac output? a. bounding pulses and mottled skin b. altered level of consciousness and thready pulses
answers 2025
As part of the preoperative teaching for the family of a child undergoing a Tetralogy of Fallot repair, the nurse tells the family upon returning to the pediatric floor that the child may: a. be placed on a reduced sodium diet b. have an activity restriction for several days c. be assigned to an isolation room d. have visits limited to a select few - correct answer ✅Answer: a. be placed on a reduced sodium diet A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to: a. observe the child closely b. allow the child to participate in activities that will not tire him c. provide for adequate periods of rest between activities d. encourage someone in the family to be with the child 24 hours a day - correct answer ✅Answer: c. provide for adequate periods of rest between activities A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which client statement MOST indicates that the client is experiencing a serious adverse reaction to aspiration? a. "I hear ringing in my ears"
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b. "I put lotion on my itchy skin" c. "My stomach hurts after I take that medicine" d. "These pills make me cough" - correct answer ✅Answer: a. "I hear ringing in my ears" Which outcome indicates that the activity restriction necessary for a 7-year-old with RF during the acute phase has been effective? a. joints demonstrate absence of permanent injury b. the resting HR is between 60 and 100 bpm c. the child exhibits a decrease in chorea movements d. the subcutaneous nodules over the joints are no longer palpable - correct answer ✅Answer: b. the resting HR is between 60 and 100 bpm When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which intervention should be the priority? a. taking vital signs ever 6 hours b. monitoring intake and output every hour c. minimizing skin discomfort d. providing passive ROM exercises - correct answer ✅Answer: b. monitoring intake and output every hour
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a. fatigue and anorexia b. fever and petechiae c. swollen neck lymph glands and lethargy d. enlarged liver and spleen - correct answer ✅Answer: b. fever and petechiae Rationale: fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal WBC's and thrombocytes by the bone marrow an put the client at risk for other infections and bleeding After teaching the parents of a child newly diagnosed with leukemia about the disease, which description if given by the parent BEST indicates understanding of the nature of leukemia? a. "The disease is an infection resulting in increased white blood cell production" b. "The disease is a type of cancer characterized by an increase in immature WBC's" c. "The disease is an inflammation associated with enlargement of the lymph nodes" d. "The disease is an allergic disorder involving increased circulating antibodies in the blood" - correct answer ✅Answer: b. "The disease is a type of cancer characterized by an increase in immature WBC's" Which medication prescription to help relieve pain in a child with leukemia should the nurse question? a. hydromorphone
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b. acetaminophen with codeine c. ibuprofen d. acetaminophen with hydrocodone - correct answer ✅Answer: c. ibuprofen Rationale: ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia A 12-year-old with leukemia will be taking vincristine. The nurse should encourage the child to eat what kind of diet? a. high-residue b. low-residue c. low-fat d. high-calorie - correct answer ✅Answer: a. high-residue Rationale: vincristine may cause constipation, so the client should be encouraged to eat a high-residue (fiber) diet A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health, the nurse should instruct the child and parents to: a. continue with immunizations b. not receive any live attenuated vaccines c. receive vitamin and mineral supplements
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f. discharge teaching - correct answer ✅Answers: a. administering oral medications c. obtaining vital signs d. monitoring hygiene An 8-week-old infant with congenital heart disease is being discharged. What is the MOST important information for the nurse to convey regarding feeding? a. allow the infant 1 hour to complete each feeding b. position the infant in an upright position after each feeding c. give feedings per nasogastric tube to conserve energy d. provide a higher calorie formula or fortified breast milk - correct answer ✅Answer: d. provide a higher calorie formula or fortified breast milk Rationale: fortified breast milk or a high-calorie formula will help the infant gain weight and conserve energy Parents bring a 10-month-old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the ED. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are the MOST appropriate? Select all that apply. a. weigh the child b. listen to bowel sounds c. palpate the anterior fontanelle
answers 2025
d. obtain vital signs e. assess pinch and quality of the child's cry - correct answer ✅Answers: a. weigh the child b. listen to bowel sounds d. obtain vital signs e. assess pinch and quality of the child's cry The nurse reports to the healthcare provider signs of increased ICP in an infant with myelomeningocele who has which finding? a. minimal lower extremity movement b. a high-pitched cry c. overflow voiding only d. a fontanelle that bulges with crying - correct answer ✅Answer: b. a high- pitched cry The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder? a. excessive CSF within the cranial cavity b. abnormally small head c. congenital absence of the cranial vault d. overriding of the cranial sutures - correct answer ✅Answer: a. excessive CSF within the cranial cavity
