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    Exam Review

    1. A nurse is collecting data from an adolescent client 24 hours after surgery. Which of the following findings should the nurse report to the primary health care provider?
      A)
      Increased weight-bearing ability on the affected leg.
      B)
      Warmth extending from the left calf to the knee.
      C)
      Temperature of 38.8° C (101.8° F).
      D)
      Itching in bilateral antecubital spaces.
    2. The nurse is reviewing collected data.Which finding is consistent with acute laryngotracheobronchitis or pneumonia?
      A)
      Stridor.
      B)
      Type of cough.
      C)
      Fever.
      D)
      Irritability.
    3. A nurse is assessing a 4-year-old client admitted to the pediatric unit for respiratory distress. Which of the following findings should be addressed immediately?
      A)
      Stridor during inspiration.
      B)
      A wet, productive cough.
      C)
      A fever of 38.5°C (101.3°F).
      D)
      Irritability reported by the caregiver.
    4. A nurse is collecting data from an adolescent client 24 hours after admission. Which of the following findings should be reported immediately?
      A)
      Oxygen saturation of 95% on 1 L oxygen via nasal cannula.
      B)
      Presence of barrel chest.
      C)
      Respiratory rate of 32/min.
      D)
      Hemoptysis of 300 mL.
    Page 1 of 16

    Exam Review

    1. A nurse is caring for a toddler who has been vomiting for the past 8 hours.Which of the following findings indicates dehydration?
      (SATA)
      A)
      Sunken anterior fontanel.
      B)
      Increased pulse rate.
      C)
      Dry mucous membranes.
      D)
      Irritability.
    2. A client reports “difficulty breathing and coughing up blood.” During the assessment, which of the following findings would require urgent intervention?
      A)
      Steatorrhea during stool analysis.
      B)
      Barrel chest identified on physical examination.
      C)
      Oxygen saturation of 95% on 1 L oxygen via nasal cannula.
      D)
      Hemoptysis of 300 mL reported by the client.
    3. A nurse is contributing to the plan of care for a school-age child who has autism and is scheduled for surgery.Which of the following interventions should the nurse include in the plan?
      A)
      Minimize physical contact with the child.
      B)
      Place the child in a semiprivate room.
      C)
      Maintain eye contact if the child is agitated.
      D)
      Leave the television on for the child during the night.
    4. A nurse is collecting data from a school-age child who has erythema infectiosum (fifth disease). The nurse should expect the rash to appear on which area of the child's body first?
      A)
      Arms.
      B)
      Legs.
      C)
      Face.
      D)
      Abdomen.
    Page 2 of 16

    Exam Review

    1. A nurse is preparing to administer a vaccine to a toddler.Which of the following actions should the nurse plan to take?
      A)
      Administer the vaccine into the dorsogluteal muscle.
      B)
      Massage the injection site for 15 seconds after administration.
      C)
      Ensure the guardian signed an informed consent form for the immunization.
      D)
      Aspirate for the presence of blood return prior to administering the vaccine.
    2. The nurse is assisting in planning care for the child.Which of the following interventions should the nurse plan to include?
      A)
      Obtain daily weights.
      B)
      Obtain blood pressure every 8 hours.
      C)
      Maintain seizure precautions.
      D)
      Maintain a sodium-restricted diet.
    3. A nurse is preparing to administer cephalexin 50 mg/kg/day in divided doses every 8 hours to a child who weighs 33 lb. The amount available is cephalexin oral suspension 250 mg/5 mL. How many mL should the nurse administer per dose?
    4. A nurse is discussing allergies with the guardians of a school-age child prior to administration of the influenza vaccine.The nurse should identify that a prior anaphylactic reaction to which of the following is a contraindication to this immunization?
      A)
      Neomycin
      B)
      Gluten
      C)
      Eggs
      D)
      Gelatin
    Page 3 of 16

    Exam Review

    1. A nurse is reinforcing teaching with the guardians of a toddler who has cystic fibrosis.Which of the following diets should the nurse recommend for the toddler?
      A)
      High protein, high calorie
      B)
      High fat, low protein
      C)
      Moderate protein, low calorie
      D)
      Low carbohydrate, high fat
    2. A nurse is collecting data from an infant who has respiratory syncytial virus (RS). Which of the following findings should the nurse expect?
      A)
      Rhinorrhea.
      B)
      Vesicles on the trunk.
      C)
      Barrel chest.
      D)
      Clubbing of the fingers.
    3. A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?
      A)
      Lower the temperature of the room.
      B)
      Place the child in an ice bath.
      C)
      Give 500 mg acetaminophen every 2 hours.
      D)
      Administer a 100 mg aspirin suppository.
    4. A nurse is caring for a toddler who has been vomiting for the past 8 hours.Which of the following findings indicates to the nurse that the child is dehydrated?
      A)
      Increased blood pressure.
      B)
      Flat anterior fontanel.
      C)
      Increased pulse.
      D)
      Distended jugular veins.
    Page 4 of 16

    Exam Review

    1. A nurse is contributing to the plan of care for a school-age child who has autism and is scheduled for surgery.Which of the following interventions should the nurse include in the plan?
      A)
      Leave the television on for the child during the night.
      B)
      Minimize physical contact with the child.
      C)
      Place the child in a semi-private room.
      D)
      Maintain eye contact if the child is agitated.
    2. The nurse is assisting in planning care for a child.Which of the following interventions should the nurse plan to include?
      A)
      Obtain daily weights.
      B)
      Obtain blood pressure every 8 hours.
      C)
      Maintain seizure precautions.
      D)
      Maintain a sodium-restricted diet.
      E)
      Maintain strict bed rest.
    3. A nurse is collecting data from a school-age child who has erythema infectiosum (fifth disease). The nurse should expect the rash to appear on which area of the child's body first?
      A)
      Face.
      B)
      Hands.
      C)
      Chest.
      D)
      Back.
    4. A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization.Which of the following findings is the nurse's priority?
      A)
      Redness at the injection site.
      B)
      Temperature 37.7°C (99.9°F).
      C)
      Hives on the child's neck.
      D)
      Prolonged crying.
    Page 5 of 16

    Exam Review

    1. A nurse is reinforcing teaching with the guardian of a school-age child who has a severe peanut allergy.Which of the following information should the nurse include?
      A)
      The child should carry an epinephrine auto-injector.
      B)
      The child should refrain from eating any type of nut.
      C)
      The child's allergy will become more severe with prolonged exposure.
      D)
      The child will likely outgrow the allergy in adolescence.
    2. A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy.Which of the following pain rating scales should the nurse use?
      A)
      Color tool.
      B)
      FLACC Scale.
      C)
      Numeric scale.
      D)
      Poker Chip Tool.
    3. A nurse is planning to collect data from an 11-month-old infant who has failure to thrive.Which of the following findings should the nurse expect?
      A)
      Makes eye contact with others.
      B)
      Poor muscle tone.
      C)
      Stranger anxiety.
      D)
      Weight above the 10th percentile.
    4. A nurse is preparing to administer recommended immunizations to an 11-year-old child who is up-to-date with current immunizations.Which of the following immunizations should the nurse plan to administer?
      A)
      Hepatitis A.
      B)
      Human papillomavirus.
      C)
      Rotavirus.
      D)
      Haemophilus influenzae type b. . .
    Page 6 of 16