The nurse is evaluating diet teaching for a client who has nontropical sprue
(celiac disease). Choosing which food indicates that the teaching has been
effective?
A. Creamed corn
B. Pancakes
C. Rye crackers
D. Cooked oatmeal - CORRECT ANSWERS-A. Creamed corn
During a well-baby check, the nurse hides a block under the baby's blanket,
and the baby looks for the block. Which normal growth and development
milestones is the baby developing?
A. Separation anxiety
B. Associative play
C. Object prehension
D. Object permanence - CORRECT ANSWERS-D. Object permanence
The nurse is measuring the frontal occipital circumference (FOC) of a 3
month old infant, and notes that the FOC has increased 5 inches since birth
and the child's head appears large in relation to body size. Which action is
most appropriate for the nurse to take next?
A. Measure the infant's head to toe length
B. Palpate the anterior fontanel for tension and bulging
C. Observe the infant for sunken eyes
D. Plot the measurement on the infant's growth chart - CORRECT ANSWERS-
B. Palpate the anterior fontanel for tension and bulging
The nurse is caring for a 3 year old child who is 2 hours postop from a
cardiac catheterization via the right femoral artery. Which assessment
finding is an indication of arterial obstruction?
A. Blood pressure trend is downward and pulse is rapid and irregular
B. Right foot I cool to the touch and appears pale and blanched
C. Pulse distal to the femoral artery is weaker on the left foot than right foot
, D. The pressure dressing at right femoral area is moist and oozing blood -
CORRECT ANSWERS-B. Right foot is cool to the touch and appears pale and
blanched
Following a motor vehicle collision, a 3 year old girl has a spica cast applied.
Which toy is best for the nurse for this 3 year old child?
A. Duck that squeaks
B. Fashion doll and clothes
C. Set of cloth and hand puppets
D. Hand held video game - CORRECT ANSWERS-C. Set of cloth and hand
puppets
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic.
Which action should the nurse implement first?
A. Administer morphine sulphate
B. Start IV fluids
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask - CORRECT ANSWERS-C. Place the
infant in a knee-chest position
A child admitted with diabetic keto acidosis is demonstrating Kussmaul
respirations. The nurse determines that the increased respiratory rate is a
compensatory mechanism for which acid baed alteration?
A. Metabolic alkalosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic acidosis - CORRECT ANSWERS-D. Metabolic acidosis
A 7 year old is admitted to the hospital with persistent vomiting, and a
nasogastric tube attached to low intermittent suction is applied. Which
finding is most important for the nurse to report to the healthcare provider?
A. Gastric output of 100 mL in the last 8 hours
B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips
C. Serum potassium of 3.0 mg/dL
D. Serum pH of 7.45 - CORRECT ANSWERS-C. serum potassium of 3.0 mg/dL
The nurse is preparing a 10 year old with a lacerated forehead for suturing.
Both parents and 12 year old sibling are at the child's bedside. Which
instruction best supports family?
A. While waiting for the healthcare provider, only one visitor may stay with
the child
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