2023 N GN RN P ediatric Nursing Online Practice A & B New
Latest Versio n with All Questions and 100% Cor rect
Answers and Rationale
A nurse is caring for a preschooler who has neutropenia. Which of the following
statements should the nurse make to the child's guardians? ---------- Correct Answer ----
---- "Avoid using your child's daycare center."
Rationale: Children who have neutropenia are immunocompromised and susceptible to
infection. Therefore, places where large groups of people gather, such as daycare
centers, should be avoided.
A nurse is caring for a preschooler whose guardian is going home for a few hours while
another relative stays with the child. Which of the following statements should the nurse
make to explain to the child when their guardian will return? ---------- Correc t Answer ----
---- "Your guardian will be back after you eat."
Rationale: Preschoolers make sense of time best when they can associate it with an
expected daily routine, such as meals and bedtime. Therefore, the child comprehends
time best when it is explained to them in relation to an event they are familiar with, su ch
as eating.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate
enema. Which of the following findings indicates effectiveness of the medication? --------
-- Correct Answer -------- Serum potassium level 4.1 mEq/L
Rationale: The nurse should monitor the adolescent's serum potassium level following
the administration of sodium polystyrene sulfonate. This medication is used to treat
hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore,
a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the
effectiveness of the medication.
A nurse is admitting a school -age child who has pertussis. Which of the following
actions should the nurse take? ---------- Correct Answer -------- Initiate droplet
precautions for the child.
Rationale: The nurse should initiate droplet precautions for a child who has pertussis,
also known as whooping cough. Pertussis is transmitted through contact with infected
large -droplet nuclei that are suspended in the air when the child coughs, sneezes, or
talks.
A nurse is providing discharge teaching to the parent of an 18 -month -old toddler who
has dehydration due to acute diarrhea. Which of the following statements by the parent
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indicates an understanding of the teaching? ---------- Correct Answer -------- "I will
monitor my child's number of wet diapers."
Rationale: The nurse should teach the parent to closely monitor the child's number of
wet diapers. Monitoring the number of wet diapers per day is an effective way for the
parent to monitor adequate output and hydration status.
A nurse is caring for a 10 -year-old child following a head injury. Which of the following
findings should the nurse identify as an indication that the child is developing diabetes
insipidus? ---------- Correct Answer -------- Sodium 155 mEq/L
Rationale: A child who has a head injury can develop diabetes insipidus as a result of
pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of
antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration . With
the excessive loss of free water, sodium levels rise above the expected reference range
of 136 to 145 mEq/L.
A nurse is caring for a school -age child who is in Buck's traction following a leg fracture
24 hr ago. Which of the following actions should the nurse take? ---------- Correct
Answer -------- Assess peripheral pulses once every 4 hr.
Rationale: Buck's traction is a type of skin traction that can be used to immobilize
extremities prior to surgery. The nurse should provide frequent neurovascular checks at
least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse s hould
monitor and report signs of neurovascular impairment in the extremities such as
cyanosis, edema, pain, absent pulses, and tingling.
A charge nurse in an emergency department is preparing an in -service for a group of
newly licensed nurses about the manifestations of child maltreatment. Which of the
following manifestations should the charge nurse include as a potential indication of
physical abuse? ---------- Correct Answer -------- Symmetric burns of the lower
extremities
Rationale: The nurse should include that symmetric burns to the lower extremities can
indicate physical abuse. The patterns are usually characteristic of the method or object
used, such as cigar or cigarette burns, or burns in the shape of an iron.
A nurse is planning an educational program for school -age children and their parents
about bicycle safety. Which of the following information should the nurse plan to
include? ---------- Correct Answer -------- The child should be able to stand on the balls of
their feet when sitting on the bike.
Rationale: To decrease the risk for injury, parents should ensure that the bike is the
correct size for the child. When seated on the bike, the child should be able to stand
with the ball of each foot touching the ground and should be able to stand with ea ch foot
flat on the ground when straddling the bike's center bar.
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A nurse is assessing a 4 -year-old child at a well -child visit. Which of the following
developmental milestones should the nurse expect to observe? ---------- Correct Answer
-------- Cuts an outlined shape using scissors
Rationale: The nurse should recognize that an expected developmental milestone of a
4-year-old child is using scissors to cut out a shape.
A nurse is assessing a school -age child immediately following a perforated appendix
repair. Which of the following findings should the nurse expect? ---------- Correct Answer
-------- Absence of peristalsis
Rationale: The nurse should expect absence of peristalsis immediately following a
perforated appendix repair, until the bowel resumes functioning.
A nurse in a health department is caring for an emancipated adolescent who has an STI
and is unaccompanied by a guardian. Which of the following actions should the nurse
take? ---------- Correct Answer -------- Have the adolescent sign a consent form for
treatment.
Rationale: The nurse should identify that an emancipated minor can sign the consent
form for treatment of an STI or any other form of medical treatment requiring consent.
A nurse is admitting a 4 -month -old infant who has heart failure. Which of the following
findings is the nurse's priority? (Click on the "Exhibit" button for additional information
about the client. There are three tabs that contain separate categories of d ata.)
Graphic Record
Temperature 37.5° C (99.5° F)
Heart rate 70/min
Respiratory rate 30/min
Birth weight 3.2 kg (7 lb)
Current weight 5.9 (13 lb)
Nurses' Notes
3 episodes of vomiting
6 wet diapers in 24 hr
Consumed 3 oz concentrated formula every 3 hr
Medication Administration Record
Digoxin 0.5 mcg PO Q12H
Furosemide 20 mg PO Q12H ---------- Correct Answer -------- Episodes of vomiting
Rationale: When using the urgent vs. non -urgent approach to client care, the nurse
should determine that the priority finding is three episodes of vomiting. This can indicate
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digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's
priority finding.
A nurse is caring for a 1 -month -old infant who is breastfeeding and requires a heel stick.
Which of the following actions should the nurse take to minimize the infant's pain? -------
--- Correct Answer -------- Allow the mother to breastfeed while the sample is being
obtained.
Rationale: The nurse should allow the mother to breastfeed the infant prior to or during
the procedure. Evidence -based practice indicates breastfeeding or non -nutritive sucking
with a pacifier can provide non -pharmacological pain management in infants.
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is
scheduled for surgery. Which of the following interventions should the nurse include? ---
------- Correct Answer -------- Avoid palpating the abdomen when bathing the child
before surgery.
Rationale: The nurse should avoid palpating the abdomen when bathing the child before
surgery because movement of the tumor can cause cancer cells to disseminate to other
sites, adjacent and distant to the tumor site.
A nurse in an emergency department is caring for a school -age child who is
experiencing an anaphylactic reaction. Which of the following is the priority action by the
nurse? ---------- Correct Answer -------- Administer epinephrine IM
Rationale: When using the urgent vs. non -urgent approach to client care, the nurse
should determine that the priority action is administering epinephrine IM to the child.
During an anaphylactic reaction, histamine release causes bronchoconstriction and
vasodilation. This is an emergency because ultimately it causes decreased blood return
to the heart.
A nurse in a pediatric emergency department is planning care for an adolescent. Based
on the information in the adolescent's medical record, which of the following actions
should the nurse plan to take?
Select all that apply. ---------- Correct Answer -------- Apply supplemental oxygen
Rationale: According to the medical record and chest x -ray report, the adolescent could
potentially have a pneumothorax. Also according to the medical record and chest x -ray
report, the adolescent's oxygen saturation level is decreasing, which indicates hy poxia.
Therefore, the nurse should plan to administer supplemental oxygen.
Prepare for chest tube insertion
Rationale: According to the medical record and chest x -ray report, the adolescent could
potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural
cavity, which results in decreased lung expansion. The adolescent could experience Powered by TCPDF (www.tcpdf.org)
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