Practice test ENPC actual
solution
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. - answer -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? - answer -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?
- answer -Sicker
The pediatric prioritization process components include the focused assessment, focused history, acuity
rating decision and: - answer -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? - answer -
Immobilize the cervical spine
