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    Exam Review

    1. A nurse is caring for a client who is postoperative following placement of a halo vest to manage a cervical vertebral fracture. Which of the following actions should the nurse take?
      A)
      Reposition the client using a turning sheet.
      B)
      Tighten the screws on the halo device one-quarter turn every 48 hr.
      C)
      Encourage flexion and extension of the neck.
      D)
      Assess the pin sites for infection once every other day.
    2. A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?
      A)
      Place the infant in a recumbent position during feeding.
      B)
      Allow the infant 45 min for each feeding.
      C)
      Allow the infant to self-soothe by crying prior to feeding.
      D)
      Implement a 3-hr feeding schedule.
    3. A nurse is evaluating the pain level of a toddler who is cognitively impaired to a non- pharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?
      A)
      FLACC
      B)
      Visual analog
      C)
      FACES
      D)
      CRIES
    4. A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?
      A)
      "Your child should walk the bicycle through intersections."
      B)
      "Your child should keep the bicycle at least 3 feet from the curb while riding in the street."
      C)
      "Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle."
      D)
      "Your child should ride the bicycle against the flow of traffic."
    Page 1 of 16

    Exam Review

    1. A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?
      A)
      Establish a reward system.
      B)
      Hold the child during assessments.
      C)
      Maintain extended eye contact.
      D)
      Engage in cooperative play.
    2. A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?
      A)
      Apply pressure just above the insertion site.
      B)
      Monitor the pulse distal to the insertion site.
      C)
      Obtain vital signs.
      D)
      Reinforce the dressing.
    3. A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?
      A)
      Increase fluid intake to 2 L/day.
      B)
      Weigh the child once per day.
      C)
      Position the child supine at bed time.
      D)
      Limit calorie intake to 45 cal/kg/day.
    4. A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis? Select all that apply.
      (SATA)
      A)
      Blood urea nitrogen (BUN)
      B)
      Partial thromboplastin time (PTT)
      C)
      C-reactive protein (CRP)
      D)
      Antistreptolysin O (ASO) titer
      E)
      Erythrocyte sedimentation rate (ESR)
    Page 2 of 16

    Exam Review

    1. A nurse is caring for a newly admitted child who has cystic fibrosis. For which of the following members of the interprofessional team should the nurse initiate a referral?
      A)
      Dietitian
      B)
      Physical therapist
      C)
      Speech-language pathologist
      D)
      Occupational therapist
    2. A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
      A)
      Doll's eye reflex intact
      B)
      No head lag when pulled to a sitting position
      C)
      Positive Babinski reflex
      D)
      Presence of tears when crying
    3. A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?
      A)
      Secure the restraints with a quick-release knot.
      B)
      Assess the child every 4 hr while in restraints.
      C)
      Tie the restraints to the side rails of the child's bed.
      D)
      Request that the provider renew the prescription for restraints every 48 hr.
    4. A nurse is reviewing the complete blood count results for a 4-year-old child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?
      A)
      Hemoglobin 6.8 g/dL (9.5 to 14 g/dL)
      B)
      WBC count 15,000/mm3 (5,000 to 10,000/mm3)
      C)
      RBC count 5/mm3 (4 to 5.5/mm3)
      D)
      Platelet count 98,000/mm3 (150,000 to 400,000/mm3)
    Page 3 of 16

    Exam Review

    1. A nurse is caring for a 5-year-old child who has acute poststreptococcal glomerulonephritis. Which of the following findings should indicate to the nurse that treatment has been effective?
      A)
      Clear urine
      B)
      No report of pain with voiding
      C)
      Odorless urine
      D)
      Temperature 37.2° C (99° F)
    2. A nurse is providing teaching to the guardian of a 2-year-old child about typical toddler behavior. Which of the following behaviors should the nurse include?
      A)
      Frequent negative responses
      B)
      Resistant to routines
      C)
      Increased dependency
      D)
      Less emotionally labile
    3. A nurse is caring for a 1-week-old newborn who has hyperbilirubinemia and is being treated with phototherapy. Which of the following actions should the nurse take?
      A)
      Monitor the newborn's temperature every 2 hr.
      B)
      Place mittens on the newborn's hands.
      C)
      Apply lotion to the newborn's skin.
      D)
      Check the newborn's eyes every 8 hr.
    4. A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
      A)
      Continuous swallowing.
      B)
      Blood pressure 95/56 mm Hg.
      C)
      Heart rate 54/min.
      D)
      Flushing of the face.
    Page 4 of 16

    Exam Review

    1. A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?
      A)
      Set the water heater to 60° C (140° F).
      B)
      Keep electrical wires hidden from view.
      C)
      Turn pot handles toward the front of the stove.
      D)
      Encourage outdoor activities between the hours of 1100 and 1300.
    2. A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
      A)
      Provide the child with a warm blanket.
      B)
      Assess the oral cavity for Koplik spots.
      C)
      Initiate airborne precautions.
      D)
      Administer aspirin for fever.
    3. A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?
      A)
      The child cries often.
      B)
      The child refuses clear liquids.
      C)
      The child's throat pain increases.
      D)
      The child swallows frequently.
    4. A nurse is preparing to assess a 4-year-old child's visual acuity. Which of the following actions should the nurse plan to take?
      A)
      Test the child without glasses before testing with glasses.
      B)
      Position the child 4.6 meters (15 feet) from the chart.
      C)
      Assess both eyes together first, then each eye separately.
      D)
      Use a tumbling E chart for the assessment.
    Page 5 of 16

    Exam Review

    1. A nurse is obtaining informed consent for an adolescent who is scheduled for a cardiac catheterization. The adolescent's guardian states, "I don't understand why they need to do this procedure." Which of the following actions should the nurse take?
      A)
      Explain the procedure to the adolescent and their guardian.
      B)
      Witness the adolescent’s signature on the informed consent form.
      C)
      Request assistance from the anesthesiologist to clarify the misunderstanding.
      D)
      Notify the provider who is scheduled to perform the procedure.
    2. A nurse is preparing to perform a venipuncture on a 4-year-old child. Which of the following actions should the nurse take to ensure atraumatic care?
      A)
      Apply a topical anesthetic cream 1 hr prior to the procedure.
      B)
      Perform the procedure in the unit's playroom.
      C)
      Ask the child's parent to leave the room during the procedure.
      D)
      Explain the procedure in detail to the child 3 hr prior to the procedure.
    3. A nurse is caring for a child who is receiving conditioning therapy for enuresis. Which of the following statements by the child's parent indicates the treatment is effective?
      A)
      “My child held their urine for about 15 minutes before going to the bathroom.”.
      B)
      “My child has been doing Kegel exercises to strengthen their pelvic muscles.”.
      C)
      “My child went to the bathroom two times when the alarm went off last night.”.
      D)
      “My child has been drinking a lot less since they started treatment.”.
    4. A nurse is providing discharge teaching to the parents of a school-age child following surgery and cast application to the right forearm. Which of the following information is the priority for the nurse to include?
      A)
      Restrict the child’s strenuous activities for 3 days.
      B)
      Use a hair dryer on a cool setting to relieve itching.
      C)
      Monitor for pallor or swelling in the child’s affected hand.
      D)
      Examine the child for skin irritation at the cast edges.
    Page 6 of 16