PEDIATRIC NURSING
1. A preschool-age child refuses to take prescribed
medication. Which nursing strategy would be most
appropriate?
a. Mixing the medication in milk so the child isn’t aware
that ifs there
b. Explaining the medications effects in detail to ensure
cooperation
c. Making the child feel ashamed for not cooperating
d. Showing trust in the child’s ability to cooperate even
with an unpleasant procedure
RATiONALES: To gain a preschooler’s cooperation. the
nurse should show trust and express faith in the child’s
ability to cooperate even with an unpleasant procedure
Hiding the medication in milk may foster mistrust The
nurse should provide simple, not detailed, explanations
and should use terms the child can understand Shaming
the child is inappropriate and may lead to feelings of
guilt.
2. Which intervention provides the most accurate
information about an infant’s hydration status?
a. Monitoring the infant’s vital signs
b. Accurately measuring intake and output
c. Monitoring serum electrolyte levels
d. Weighing the infant daily
RATIONALES: Weighing an infant daily provides the most
accurate information about the infant’s hydration status
Vital signs, intake and output, and electrolyte levels
provide helpful information about an infant’s hydration
status, but they aren’t as accurate as weighing daily
3. Laboratory results for a child with a congenital heart
defect with decreased pulmonary blood flow reveal an
elevated hemoglobin(Hb) level. hematocrit(HCT), and
red blood cell (RBC) count. These data suggest which
condition?
a. Anemia
b. Dehydration
c. Jaundice
d. Compensation for hypoxia
RATIONALES: A congenital heart defect with decreased
pulmonary blood flow alters blood flow through the
heart and lungs. resulting in hypoxia To compensate, the
body increases the oxygen-carrying capacity of RBCs by
increasing RBC production, which causes the Hb level
and HCT to rise. In anemia, the Hb level and HCT
typically decrease. Altered electrolyte levels and other
laboratory values are better indicators of dehydration
An elevated Hb level and HCT aren’t associated with
jaundice
4. An adolescent girl who’s receiving chemotherapy for
leukemia is admitted for pneumonia The adolescent’s
platelet count is 50.000 pl. Which of the following would
be inappropriate to include in the care plan?
a. A sign over the bed that reads “NO NEEDLE STICKS
AND NOTHING PER RECTUM”
b. Two peripheral LV intermittent infusion devices, one
for blood draws and one for infusions
c. Administration of oxygen at a rate of 4 Liminute
using a nonhumidified nasal cannula
d. Use of a tympanic membrane sensor to measure her
temperature at the bedside
RATIONALES: Oxygen should be humidified to assure
that irritation of the mucosa doesn’t occur. This teen’s
platelet level is decreased, so she’s at risk for bleeding
The nose is a vascular region that can bleed easily if the
mucosa is dried by the oxygen. A sign to remind others
to avoid needle sticks and to not give anything via the
rectum, the presence of two peripheral LVs. and the use
of a tympanic temperature device are all aspects of care
that would decrease the client’s risk of bleeding
5. A child, age 2 is brought to the emergency
department after ingesting an unknown number of
aspirin tablets about 30 minutes earlier. Qn entering the
examination room, the child is crying and clinging to the
mother Which data should the nurse obtain first?
a. Heart rate, respiratory rate. and blood pressure
b. Recent exposure to communicable diseases
c. Number of immunizations received
d. Height and weight
6. A 15-year-old girl visits the neighborhood clinic
seeking information on “how to keep from getting
pregnant” What should the nurse say in response to her
request?
a. ‘What would you like to know?”
b. “Let’s discuss what your friends are doing to keep
from getting pregnant”
c. I “Can you tell me if you’ve told your parents you’re
having sex?”
d. “Can you tell me about the precautions you’re taking
now?”
7. For a child with a WiIms tumor, which preoperative
nursing intervention takes highest priority?
a. Restricting oral intake
b. Monitoring acid-base balance
c. Avoiding abdominal palpation
d. Maintaining strict isolation
RATIONALES: Because manipulating the abdominal mass
may disseminate cancer cells to adjacent and distant
sites, the most important intervention for a child with a
Wilms tumor is to avoid palpating the abdomen.
Restricting oral intake and monitoring acid-base balance
are routine interventions for all preoperative clients:
they have no higher priority in one with a Wilms tumor.
Isolation isnt required because a Wilms tumor isnt
infectious.
8. A preschool-age child is admitted to the facility with
nephrotic syndrome. Nursing assessment reveals a
blood pressure of 100160 mm Hg. Lethargy, generalized
edema, and dark, frothy urine After prednisone
(Deltasone) therapy is initiated, which nursing action
takes highest priority?
a. Monitoring the child for hypertension
b. Turning and repositioning the child frequently
c. Providing a high-sodium diet
d. Discussing the adverse effects of steroids with the
parents
RATIONALES: The child with nephrotic syndrome is at
risk for skin breakdown from generalized edema.
Because this syndrome typically impairs independent
movement, the nurse must turn and reposition the child
frequently to help prevent skin breakdown. Frequent
turning also helps prevent respiratory infections, which
may arise during the edematous phase of nephrotic
syndrome. The syndrome typically causes hypotension,
not hypertension, from significant loss of intravascular
protein and a subsequent drop in oncotic pressure
Dietary sodium should be restricted because it worsens
edema. Although the nurse should discuss the adverse
effects of steroids with the parents, This isnt a priority at
this time.
9. During chemotherapy for lymphoma, a child, age 15,
is at risk for stomatitis. Which statement by the child
supports a nursing diagnosis of Deficient knowledge
related to mouth care?
a. “I use a soft toothbrush to clean my teeth”
b. remove white patches on my tongue and cheeks
with my toothbrush”
c. “1 rinse my mouth every 2 to 4 hours with a solution
of baking soda and water°
d. I don’t use bottled mouthwashes”
RATIONALES: White patches on the tongue and oral
mucosa indicate infection: the client should report, not
remove them. The child should use a soft toothbrush to
prevent injury to the fragile oral mucosa. To prevent
stomatitis, the child should rinse the mouth every 2 to 4
hours with a nonirritating solution, such as baking soda
and water or normal saline solution, and should avoid
commercial mouthwashes containing alcohol, which
may dry the oral mucosa.
10. A preschool-age child with sickle cell anemia is
admitted to the health care facility in vaso-occlusive
crisis after developing a fever and joint pain What is the
nurse’s highest priority when caring for this child?
a. Providing fluids
b. Maintaining protective isolation
c. Applying cool compresses to affected joints
d. Administering antipyretics as prescribed
RATIONALES: During a vaso-occlusive crisis, sickle-
shaped red blood cells (RBC5) clump together and
obstruct blood vessels, causing ischemia and tissue
damage. Providing I.V. and oral fluids promotes
hemodilution. Which aids the free flow of ROCs through
blood vessels. The client must be kept away from known
infection sources but doesn’t require protective
isolation Warm compresses may be applied to painful
joints to promote comfort: cool compresses would
cause vasoconstriction, which exacerbates sickling.
Antipyretics may be administered to reduce fever but
don’t play a crucial role in resolving the crisis.
11. When caring for a 12-month-old infant with
dehydration and metabolic acidosis, the nurse expects
to see which of the following?
a. A reduced white blood cell (WBC) count
b. A decreased platelet count
c. Shallow respirations
d. Tachypnea
RATIONALES: The body compensates for metabolic
acidosis via the respiratory system, which tries to
eliminate the buffered acids by increasing alveolar
ventilation through deep, rapid respirations. Altered
WBC and platelet counts aren’t specific signs of
metabolic imbalance.
12. The school nurse is evaluating a 7-year-old client
who is having an asthma attack. The client is cyanotic
and unable to speak with decreased breath sounds and
shallow respirations. Based on these physical findings,
the nurse should first:
a. monitor the client with a pulse oximeter in her office.
b. prepare to ventilate the client
c. return the client to class.
d. contact the clients parent or guardian.
RATIONALES: The nurse should recognize these physical
findings as signs and symptoms of impending
respiratory collapse. The nurse’s top priority is to assess
airway, breathing, and circulation, and prepare to
ventilate the client if necessary. The nurse should then
notify the emergency medical systems (EMS) to
transport the client to a local hospital When the clients
condition allows, the nurse can notify the parents or
guardian This client shouldn’t be returned to class
Because the clients condition requires immediate
intervention, simply monitoring pulse oximetry
would delay treatment
13. The physician prescribes digoxin (Lanoxin) elixir for a
toddler with heart failure. Immediately before
administering this drug, the nurse must check the
toddle(s:
a. serum sodium level
b. urine output
c. weight
d. apical pulses
14. A toddler is brought to the emergency department
with sudden onset of abdominal pain, vomiting, and
stools that look like red currant jelly. To confirm
intussusception. the suspected cause of these findings,
the nurse expects the physician to order:
a. a barium enema.
b. suprapubic aspiration.
c. nasogastric (NG) tube insertion.
d. indwelling urinary catheter insertion.
15. A 6-year-old client has tested positive for West Nile
virus infection. The nurse suspects the client has the
severe form of the disease when she recognizes which
signs and symptoms?
a. Fever, rash, and malaise
b. Anorexia, nausea, and vomiting
c. Fever, muscle weakness, and change in mental
status
d. Fever, lymphadenopathy, and rash
RATIONALES: Severe West Nile virus infection (also
called West Nile encephalitis or West Nile meningitis)
affects the central nervous system and may cause
headache, neck stiffness, fever, muscle weakness or
paralysis. changes in mental status, and seizures Such
signs and symptoms as fever, rash, malaise, anorexia,
nausea and vomiting, and lymphadenopathy suggest the
mild form of West Nile virus infection
16. A pediatric client with iron deficiency anemia is
prescribed ferrous sulfate (Ferralyn), an oral iron
supplement. When teaching the child and parent how to
administer this preparation, the nurse should provide
which instruction?
a. “Administer ferrous sulfate with meals to prevent
stomach upset”
b. “Administer ferrous sulfate with milk to promote
absorption”
c. “Administer ferrous sulfate with fruit juice to
promote absorption.”
d. “Administer ferrous sulfate with antacids to prevent
stomach upset.”
RATIONALES: Administering an oral iron supplement
such as ferrous sulfate with fruit juice or another
vitamin C source enhances its absorption Preferably.
doses should be administered between meals because
gastric acidity and absence of food promote iron
absorption In contrast. food, milk, and antacids impair
iron absorption.
17. A boy, age 3, develops a fever and rash and is
diagnosed with rubella His mother has just given birth to
a baby girl Which statement by the mother best
indicates that she understands the implications of
rubella?
a. “I told my husband to give my son aspirin for his
fever”
b. I’ll ask the physician about giving the baby an
immunization shot”
c. “1 don’t have to worry because I’ve had the measles”
d. “I’ll call my neighbor who’s 2 months pregnant and
tell her not to have contact with my son-”
RATIONALES: Fetal defects can occur during the first
trimester of pregnancy if the pregnant woman contracts
rubella Aspirin shouldn’t be given to young children
because aspirin has been implicated in the development
of Reyes syndrome. Tylenol should be used instead of
aspirin Rubella immunization isn’t recommended for
children until ages 12 to 15 months Measles is rubeola
and won’t provide immunity for rubella
18. An adolescent is diagnosed with iron deficiency
anemia. After emphasizing the importance of
consuming dietary iron, the nurse asks the child to
select iron-rich breakfast items from a sample menu
Which selection demonstrates knowledge of dietary iron
sources?
a. Grapefruit and toast
b. Pancakes and a banana
c. Ham and eggs
d. Bagel and cream cheese
19. Which of the following objects poses the most
serious safety threat to a 2-year-old child in the
hospital?
a. Crayons and paper
b. Stuffed teddy bear in the crib
c. Mobile hanging over the crib
d. Side rails in the halfway position
RATIONALES: To prevent falls — one of the most
common accidents in hospitals — the crib rails always
should be raised and fastened securely unless an adult is
at the bedside Crayons and paper and a stuffed teddy
bear are safe toys for a 2-year-old child. Although a
mobile could pose a safety threat to this child, the
threat is less serious than that posed by an incorrectly
positioned side rail
20. A 2-year-old child is brought to the emergency
department with suspected croup. Which of the
following assessment findings reflects increasing
respiratory distress?
a. Intercostal retractions
b. Bradycardia
c. Decreased level of consciousness
d. Flushed skin
21. The mother of a 4-year-old child tells the pediatric
nurse that the child’s abdomen seems to be swollen.
During further assessment, the mother tells the nurse
that the child is eating well and that the activity level of
the child is unchanged. The nurse, suspecting the
possibility of Wilms’ tumor, should avoid which during
the physical assessment?
a. Palpating the abdomen for a mass
b. Assessing the urine for the presence of hematuria
c. Monitoring the temperature for the presence of fever
d. Monitoring the blood pressure for the presence of
hypertension
Rationale: Wilms’tumor is the most common
intraabdominal and kidney tumor of childhood. If Wilms’
tumor is suspected, the tumor mass should not be
palpated by the nurse. Excessive manipulation can cause
seeding of the tumor and spread of the cancerous cells.
Hematuria, fever, and hypertension are clinical
manifestations associated with Wilms’ tumor.
22. Which specific nursing interventions are
implemented in the care of a child with leukemia who
is at risk for infection? Select all that apply.
1. Maintain the child in a semiprivate room.
2. Reduce exposure to environmental organisms.
3. Use strict aseptic technique for all procedures.
4. Ensure that anyone entering the child’s room wears
a mask.
5. Apply firm pressure to a needle-stick area for
at least 10 minutes.
a. 1,2,4 b. 2,3,4 c. 3,4,5 d. 2,3,5
Rationale: Leukemia is a malignant increase in the
number of leukocytes, usually at an immature stage, in
the bone marrow. It affects the bone marrow, causing
anemia from decreased erythrocytes, infection from
neutropenia, and bleeding from decreased platelet
production (thrombocytopenia). A common
complication of treatment for leukemia is overwhelming
infection secondary to neutropenia. Measures to
prevent infection include the use of a private room,
strict aseptic technique, restriction of visitors and health
care personnel with active infection, strict hand
washing, ensuring that anyone entering the child’s room
wears a mask, and reducing exposure to environmental
organisms by eliminating raw fruits and vegetables
from the diet and fresh flowers from the child’s room
and by not leaving standing water in the child’s room.
Applying firm pressure to a needle-stick area for at least
10 minutes is a measure to prevent bleeding.
23. An adolescent client with type 1 diabetes mellitus
is admitted to the emergency department for treatment
of diabetic ketoacidosis. Which assessment
findings should the nurse expect to note?
a. Sweating and tremors
b. Hunger and hypertension
c. Cold, clammy skin and irritability
d. Fruity breath odor and decreasing level of
consciousness
24. A child with type 1 diabetes mellitus is brought
to the emergency department by the mother,
who states that the child has been complaining
of abdominal pain and has been lethargic. Diabetic
ketoacidosis is diagnosed. Anticipating the plan of care,
the nurse prepares to administer which type of
intravenous (IV) infusion?
a. Potassium infusion
b. NPH insulin infusion
c. 5% dextrose infusion
d. Normal saline infusion
25. The nurse should implement which interventions
for a child older than 2 years with type 1 diabetes
mellituswho has a blood glucose level of 60 mg/dL
(3.4 mmol/L)? Select all that apply.
1. Administer regular insulin.
2. Encourage the child to ambulate.
3. Give the child a teaspoon of honey.
4. Provide electrolyte replacement therapy
intravenously.
5. Wait 30 minutes and confirm the blood glucose
reading.
6. Prepare to administer glucagon subcutaneously
if unconsciousness occurs.
a. 1,3,6 b. 3,5,6 c. 3,6 d. 5,6
26. The clinic nurse reviews the record of an infant and
notes that the health care provider has documented
a diagnosis of suspected Hirschsprung’s disease.
The nurse reviews the assessment findings
documented in the record, knowing that which
sign most likely led the mother to seek health care
for the infant?
a. Diarrhea
b. Projectile vomiting
c. Regurgitation of feedings
d. Foul-smelling ribbon-like stools
27. An infant has just returned to the nursing unit after
surgical repair of a cleft lip on the right side. The
nurse should place the infant in which best position
at this time?
a. Prone position
b. On the stomach
c. Left lateral position
d. Right lateral position
Rationale: A cleft lip is a congenital anomaly that occurs
as a result of failure of soft tissue or bony structure to
fuse during embryonic development. After cleft lip
repair, the nurse avoids positioning an infant on the side
of the repair or in the prone position because these
positions can cause rubbing of the surgical site on the
mattress. The nurse positions the infant on the side
lateral to the repair or on the back upright and positions
the infant to prevent airway obstruction by secretions,
blood, or the tongue. From the options provided,
placing the infant on the left side immediately after
surgery is best to prevent the risk of aspiration if the
infant vomits.
28. The nurse provides feeding instructions to a parent
of an infant diagnosed with gastroesophageal reflux
disease. Which instruction should the nurse give to the
parent to assist in reducing the episodes of emesis?
a. Provide less frequent, larger feedings.
b. Burp the infant less frequently during feedings.
c. Thin the feedings by adding water to the formula.
d. Thicken the feedings by adding rice cereal to the
formula.
Rationale: Gastroesophageal reflux is backflow of gastric
contents into the esophagus as a result of relaxation or
incompetence of the lower esophageal or cardiac
sphincter. Small, more frequent feedings with frequent
burping often are prescribed in the treatment of
gastroesophageal reflux. Feedings thickened with rice
cereal may reduce episodes of emesis. If thickened
formula is used, cross-cutting of the nipple may be
required.
29. After a tonsillectomy, a child begins to vomit bright
red blood. The nurse should take which initial action?
a. Turn the child to the side.
b. Administer the prescribed antiemetic.
c. Notify the health care provider (HCP).
d. Maintain NPO (nothing by mouth) status.
Rationale: After tonsillectomy, if bleeding occurs, the
nurse immediately turns the child to the side to prevent
aspiration and then notifies the HCP. NPO status would
be maintained, and an antiemetic may be prescribed;
however, the initial nursing action would be to turn the
child to the side.
30. A child has been diagnosed with acute otitis media
of the right ear. Which interventions should the
nurse include in the plan of care? Select all that apply.
1. Provide a soft diet.
2. Position the child on the left side.
3. Administer an antihistamine twice daily.
4. Irrigate the right ear with normal saline every 8 hours.
5. Administer ibuprofen for fever every 4 hours as
prescribed and as needed.
6. Instruct the parents about the need to administer
the prescribed antibiotics for the full course of therapy.
Rationale: Acute otitis media is an inflammatory
disorder
caused by an infection of the middle ear. The child often
has fever, pain, loss of appetite, and possible ear
drainage. The child also is irritable and lethargic and
may roll the head or pull on or rub the affected ear.
Otoscopic examination may reveal a red, opaque,
bulging, and immobile tympanic membrane. Hearing
loss may be noted particularly in chronic otitis media.
The child’s fever should be treated with ibuprofen. The
child is positioned on his or her affected side to facilitate
drainage. A soft diet is recommended during the acute
stage to avoid pain
that can occur with chewing. Antibiotics are prescribed
to treat the bacterial infection and should be
administered for the full prescribed course. The ear
should not be irrigated with normal saline because it can
exacerbate the inflammation further. Antihistamines are
not usually recommended as a part of therapy.
31. The nurse is caring for an 8-year-old child with acute
asthma exacerbation. Which of the following would be
of greatest concern to the nurse?
a. The child’s respiratory rate is now 24 breaths/minute
b. Recent blood gas analysis indicates an oxygen
saturation of 96W
c. Before a respiratory therapy treatment, wheezing
isn’t heard on auscultation
d. The child’s mother reports that the child sometimes sunken eyeballs indicate dehydration. not increased ICR
forgets to take the inhalers With increased ICP, the heart rate decreases
RATIONALES: Typically, before a respiratory therapy
treatment, wheezing has increased and the client has 36. Which intervention takes priority when admitting an
increased respiratory distress. No wheezing on infant with acute gastroenteritis?
auscultation is an indication that the child isn’t moving a. Obtaining a stool specimen
air in and out and is in respiratory distress. A respiratory b. Weighing the infant
rate of 24 breaths/minute in an 8-year-old child is c. Offering the infant clear liquids
normal. An oxygen saturation of 95% is somewhat of a d. Obtaining a history of the illness
concern, possibly indicating that the client needs oxygen
or needs to clear the airways The fact that the mother 37. A neonate born several hours ago shows signs of a
makes the 8-year-old child responsible for taking tracheoesophageal fistula (TEF). During the initial
medications is of concern and needs to be investigated, assessment,
but this isn’t as important at this time as the lack of what does the nurse expect to find?
wheezing a. Continuous drooling
b. Diaphragmatic breathing
32. A toddler with a ventricular septal defect IVSD) is c. A slow response to stimuli
receiving digoxin (Lanoxin) to treat heart failure The d. Passage of frothy meconium
nurse should monitor the child for early signs of digoxin
toxicity. which include: 38. Which technique is most effective in preventing
a. bradycardia nosocomial infection transmission when caring for a
b. tachycardia preschooler?
c. hypertension a. Client isolation
d. hyperactivity b. Standard precautions
c. Hand washing
33. Which of the following should the nurse do first d. Needleless syringe system
when admitting an 11-year-old child in sickle cell crisis?
a. Administer oral pain medication while obtaining the 39. The nurse is teaching accident prevention to the
child’s history parents of a toddler. Which instruction is appropriate
b. Begin I.V. fluids after obtaining the child’s history. for the nurse to
c. Instruct the parents about what to expect during this tell the parents?
hospitalization a. The toddler should wear a helmet when roller
d. Start oxygen therapy as soon as the child’s vital signs blading.
are taken b. Place locks on cabinets containing toxic substances.
RATIONALES: Fluids are one of the most important c. Teach the toddler water safety.
components of therapy for sickle cell crisis Fluids help d. Don't allow the toddler to use pillows when sleeping.
increase blood volume and prevent sickling and
thrombosis A child experiencing a sickle cell crisis often 40. Twenty-four hours after birth, a neonate hasn't
has severe pain requiring the use of LV. analgesics such passed meconium. The nurse suspects which condition?
as morphine, which would be administered after fluid a. Hirschsprung's disease
therapy has been started. Instructing the parents about b. Celiac disease
what to expect during hospitalization is important but it c. Intussusception
isn’t the first action the nurse should take. Oxygen d. Abdominal wall defect
therapy is used only if the child is hypoxic.
41. In a pediatric client, what is an early sign of acute
34. A child, age 4, is admitted with a tentative diagnosis renal failure (ARF)?
of congenital heart disease. When assessment reveals a a. Hypertension
bounding radial pulse coupled with a weak femoral b. Decreased urine output
pulse, the nurse suspects that the child has: c. Anemia
a. patent ductus arteriosus. d. Hematuria
b. coarctation of the aorta.
c. a ventricular septal defect. 42. A 4-year-old girl has a urinary tract infection (UTI).
d. truncus arteriosus. When teaching the parents how to help her avoid
recurrent UTIs,
35. An infant undergoes surgery to remove a the nurse should emphasize which preventive measure?
myelomeningocele.To detect increased intracranial a. Wiping her perineum from back to front after she
pressure (ICP) as early as possible the nurse should stay uses the toilet
alert for which postoperative finding? b. Administering prophylactic antibiotics
a. Decreased urine output c. Giving her a warm bath for 15 minutes daily
b. Increased heart rate d. Making sure she avoids bubble baths
c. Bulging fontanels
d. Sunken eyeballs 43. When assessing a child with juvenile
RATIONALES: Because an infant’s fontanels remain hypothyroidism, the nurse expects which finding?
open. the skull may expand in response to increased ICR a. Goiter
Therefore, bulging fontanels are a cardinal sign of b. Recent weight loss
increased ICP in an infant Decreased urine output and c. Insomnia
d. Tachycardia

44. A child with diabetes insipidus receives
desmopressin acetate (DDAVP). When evaluating for
therapeutic
effectiveness, the nurse would interpret which finding
as a positive response to this drug?
a. Decreased urine output
b. Increased urine glucose level
c. Decreased blood pressure
d. Relief of nausea
45. A child is diagnosed with pituitary dwarfism. Which
pituitary agent will the physician probably prescribe to
treat this
condition?
a. corticotropin zinc hydroxide (Cortrophin-Zinc)
b. somatrem (Protropin)
c. desmopressin acetate (DDAVP)
d. vasopressin (Pitressin)
46. When discharging a 5-month-old infant from the
hospital, the nurse checks to see whether the parent's
car restraint
system for the infant is appropriate. Which of the
following restraint systems would be safest?
a. A front-facing convertible car seat in the middle of the
back seat
b. A rear-facing infant safety seat in the front passenger
seat
c. A rear-facing infant safety seat in the middle of the
back seat
d. A front-facing convertible car seat in the back seat
next to the window
47. A 12-month-old child fell down the stairs and a
basilar skull fracture is suspected. The nurse should look
for:
a. cerebrospinal fluid otorrhea.
b. deafness.
c. raccoon eyes.
d. Battle's sign.
48. The nurse is caring for an 8-year-old child with acute
asthma exacerbation. Which of the following would be
of
greatest concern to the nurse?
a. The child's respiratory rate is now 24 breaths/minute.
b. Recent blood gas analysis indicates an oxygen
saturation of 95%.
c. Before a respiratory therapy treatment, wheezing
isn't heard on auscultation.
d. The child's mother reports that the child sometimes
forgets to take the inhalers.
49. When performing a physical assessment on a girl,
age 10, the nurse keeps in mind that the first sign of
sexual
maturity in girls is:
a. breast bud development.
b. pubic hair.
c. axillary hair.
d. menarche.
50. The parents of a child with cystic fibrosis ask the
nurse why their child must receive supplemental
pancreatic
enzymes. Which response by the nurse would be most
appropriate?
a. "Pancreatic enzymes promote absorption of
nutrients and fat."
b. "Pancreatic enzymes promote adequate rest."
c. "Pancreatic enzymes prevent intestinal mucus
accumulation."
d. "Pancreatic enzymes help prevent meconium ileus."
MEDICAL-SURGICAL NURSING
Situation: You are assigned in the neurology stroke unit.
To prepare for this assignment, you should be able to
answer the following questions.
51. Which of the following statements can best describe
/ define stroke or brain attack:
a. It occurs when circulation to a part of the brain is
disrupted
b. It is usually caused by abuse of prescribed
medications
c. It is caused by a cerebral hemorrhage
d. It may be the results of a transient ischemic attack
(TIA)
52. Several diagnostic tests may be ordered for proper
evaluation. The purpose of each of the following
diagnostic exam is correct EXCEPT:
a. Cerebral angiography – is used to identify collateral
blood circulation and may reveal site of rupture or
occlusion
b. ECG – may reveal abnormal electrical activity, such as
focal slowing and assess amount of brain wave activity
c. MRI – may reveal the site of infarction, hematoma,
and shift of brain structures
d. PET scanning – may reveal information on cerebral
metabolism and blood flow characteristics
53. Which of the following is the most common cause of
stroke or brain attack:
a. Embolism
b. Hemorrhage
c. Cerebral arterial spasm
d. Thrombosis
54. To guide you in your assessment, it is also important
for you to remember that the clinical features of stroke
vary with the following factors EXCEPT:
a. Severity of damage
b. Gender
c. Artery affected
d. The extent of collateral circulation
55. It is important for you to also teach clients and their
families who are at risk to observe primary prevention
which includes the following:
a. Maintain serum cholesterol level between 180 and
220 mg/dL
b. Treat TIA early
c. Teach preventive health behaviors (consequences of
smoking, obesity, alcoholism, drug abuse) to children
of patients with stroke
d. Screen for systolic hypertension
CARE OF THE PATIENT WITH RENAL FAILURE
56. How many percent of cardiac output must the
kidneys have?
a. 20-25%
b. 15-20%
c. 10-20%
d. 25-35%
57. The following are causes of renal failure except:
a. Nephrotoxicity
b. Cardiac Tamponade
c. UTI
d. none of the above
58. Phases of acute renal failure:
a. Initiation, oliguric, diuresis, recovery
b. Initiation, diuresis, oliguric, recovery
c. Emergent, oliguric, diuresis, recovery
d. Emergent, Intermediate, Recovery
59. A patient with acute renal failure is on oliguric
phase. Which of the following is the appropriate nursing
intervention in this situation?
a. Encourage fluid intake
b. Passive range of motion exercises
c. Restricting fluids
d. Fresh fruits to increase immunity
60. Hyperkalemia in a patient with renal failure is a fatal
condition because hyperkalemia can result to:
a. Increase muscle weakness
b. cardiac dysrhythmias
c. Facial twitching
d. Decrease LOC
SITUATION:
Mr. Perez was diagnosed is a patient with Chronic Renal
Failure. The doctor ordered dialysis for the meantime
until a donor is available for Kidney Transplantation. As
a nurse, you are to evaluate his response to this
physiologic and psychosocial alteration.
61. A client with chronic renal failure is receiving a
hemodialysis treatment. After hemodialysis, the nurse
knows that the client is most likely to experience:
a. Hematuria
b. Weight loss
c. Increased urine output
d. Increase blood pressure
62. A client with chronic renal failure is undergoing
dialysis. You taught him to limit his sodium intake and
you told him about the use of Salt substitute. You
correctly explained to him that:
a. Do not use salt substitutes because some of them
contain potassium and it could cause fatal arrhythmias
and asystole
b. Never use salt substitutes because it contains higher
amount of sodium and might contribute to your edema
c. Salt substitute is only taken if the Sodium intake
exceeded the limit
d. Salt substitutes is recommended than the usual table
salt because it contains less sodium that might
contribute to hypertension and water retention to the
patient with chronic renal failure
63. A client on dialysis frequently experience the
psychologic problem of:
a. Reactive depression
b. Superego constriction
c. Postpartum psychosis
d. Disequillibrium syndromes
64. Mr. Perez is taking Furosemide (Lasix) to relieve
edema. The nurse should monitor the client for
evidence of:
a. Negative nitrogen balance
b. Excessive retention of sodium ions
c. Excessive loss of potassium ions
d. Elevation of the urine-specific gravity
65. The most important test used to determine whether
a client’s newly transplanted kidney is working is a:
a. Renal Scan
b. 24-hour urine output
c. Serum Creatinine
d. White blood cell count
66. Which of the following is a sign that the nurse could
observe in acute transplant rejection in patient after
kidney transplant?
a. Polyuria
b. Fever and chills
c. Weight loss
d. Rising BUN and Creatinine more than 20%
67. A male client who is to have a kidney transplant asks
the nurse how long will he be taking azathioprine
(IMURAN), cyclosporine and prednisone. The nurse
recognizes that the client understood the teaching when
he states “I must take these medications:
a. For the rest of my life.”
b. Until the surgery is over.”
c. Until the anastomosis heals.”
d. During the post operative period.”
68. One hour after receiving 7 U of regular insulin, the
client presents with diaphoresis, pallor, and tachycardia.
The priority nursing action would be to
a. notify the physician.
b. call the lab for a blood glucose level.
c. offer the client milk and crackers.
d. administer glucagon.
69. A patient who has Systemic Lupus Erythematosus
(SLE) is taking prednisone (Deltasone) maintainance for
life. During client teaching, the nurse stresses the
importance of taking prednisone exactly as prescribed
and cautions against discontinuing the drug abruptly. A
client who discontinues prednisone abruptly may
experience:
a. Hyperglycemia and glycosuria.
b. Acute adrenocortical insufficiency.
c. Cushing’s Disease
d. Peptic Ulcer
70. The nurse knows before puncturing the artery,
Allen’s Test must be perform. What is the purpose of
this?
a. To determine level of oxygenation in the blood
b. To determine patency of the brachial artery
c. To determine patency of ulnar artery
d. To determine partial pressure of oxygen in the blood
 b. The nurse should rotate the injection site to prevent
SITUATION : subcutaneous tissue irritation.
A client was rushed in the E.R Because of third degree c. Insulin are administer directly from the refrigerator.
burns sustained all over the body. d. Insulin injection are carefully spaced apart atleast
an inch away from one another to prevent
71. During the Acute phase of burn, the priority nursing lipodystrophy.
intervention in caring for this client is:
a. Prevention of infection 79.In diabetes mellitus Type 1, insulin deficiency or its
b. Pain management total absence can lead to fat breakdown that can
c. Prevention of Bleeding eventually lead to ketosis. The nurse knows that the acid
d. Fluid Resuscitation base disturbance associated with DKA is:
a. Metabolic Acidosis
72. The nurse knows that the most fatal electrolyte b. Respiratory Acidosis
imbalance in burned client during the Emergent phase c. Metabolic Alkalosis
of burn is: d. Respiratory Alkalosis
a. Hypokalemia
b. Hyperkalemia 80. In a client with DM 1 with persistent elevated blood
c. Hypernatremia glucose level of 240 mg/dl or more. Ketosis should be
d. Hyponatremia suspected. The nurse knows that to detect ketosis,
which of the following specimen is obtained?
73. Hypokalemia is reflected in the ECG by which of the a. Sputum b. Urine c. Feces d. Saliva
following?
a. Tall T waves SITUATION: Foot care among patients with peripheral
b. Widening QRS Complex vascular problems is very important
c. Pathologic Q wave
d. U wave 81. When teaching a client with peripheral vascular
disease about foot care, you should include which
74. Knowledge of the pathophysiology of burn is instructions:
essential in caring for a burned client. The nurse knows a. Avoid wearing canvass shoes
the during the Emergent phase of burn, The movement b. Avoid using a nail clipper to cut the nails
of fluids is: c. Avoid use of cornstarch on the foot
a. From the Intracellular space going to the extracellular d. Avoid wearing cotton socks
space
b. From the Interstitial space going to the intravascular 82. FT, who has no known history of PVD comes to the
space ER complaining of sudden onset of lower leg pain.
c. From the Extracellular space going to the intracellular Inspection and palpation reveal absent pulses,
space paresthesia and a mottled, cyanotic, cold, cadaverous
d. From the Intravascular space going to the interstitial left calf. While the physician determines the appropriate
space management, you should:
a. Shave the affected leg in anticipation of surgery
75. The nurse is aware that in Emergent phase of burn, b. Place a heating pad around the calf
The most common cause of death is usually due to: c. Keep the affected leg level or slightly dependent
a. Bleeding d. Elevate the affected calf as high as possible
b. Burn Shock
c. Infection 83. What is the earliest manifestation of peripheral
d. Myocardial Infarction neuropathy?
a. Paresthesia
PATIENT WITH ENDOCRINE DISORDERS b. burning sensations specially in the morning
Situation: Knowledge of insulin preparation and c. Prickling or heightened sensation with episodes of
administration is of key importance in the management sharp pain
of diabetes. d. Numbness

76.If ketosis is present, the nurse knows that insulin to 84. Peripheral neuropathy can best be controlled by:
be given is: a. Good glucose control
a. NPH b. Humulin R c. Lente d. Humulin N b. Steroid therapy
c. Vitamin supplement
77.The acronym NPH stands for: d. Nothing, there is no slowing the process
a. Normal Protein Humalog
b. Normal Protein Hagedorn 85. In addition to clients with DM you must be aware
c. Neutral Protamine Humalog that acute hypoglycemia can also develop in a client
d. Neutral Protamine Hagedorn with:
a. Hypertension
78.Which of the following is true with regards to insulin b. Hyperthyroidism
absorption? c. Liver disease
a. The fastest absorption occurs in the subcutaneous d. Diabetes insipidus
tissues of the arm.
86. Which safety measure should the nurse use for a
client who has Cushing's disease?
a. Pad the siderails of the client's bed.
b. Assist the client to change positions frequently.
c. Use a lift sheet to change the client's position.
d. Keep suctioning equipment at the client's bedside.
87. Which safety measure should the nurse use for a
client who has adrenocortical insufficiency?
a. Pad the siderails of the client's bed.
b. Assist the client to change positions slowly
c. Use a lift sheet to change the client's position.
d. Keep suctioning equipment at the client's bedside.
88. The client with hyperaldosteronism is being treated
with spironolactone therapy. What precautions should
the nurse teach this client?
a. “Avoid salt substitutes.”
b. “Avoid adding salt to food.”
c. “Avoid excessive exposure to sunlight.”
d. “Avoid acetaminophen and acetaminophen-
containing products.”
89. What is the priority nursing diagnosis for the client
with hypothyroidism?
a. Hypothermia
b. Disturbed Body Image
c. Disturbed Thought Processes
d. Imbalanced Nutrition: More than Body Requirements
90. When taking the blood pressure of a client after a
parathyroidectomy, the nurse notes that the client's
hand has gone into flexion contractions. What is the
nurse’s interpretation of this observation?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypocalcemia
SITUATION: Thyroid glands are important in metabolism
in the body. The nurse has recently admitted with fixed
stare, weight loss and tachycardia
91. What is the condition the client is exhibiting?
a. Hyperthyroidism
b. Hypothyroidism
c. Cushing’s Syndrome
d. Addison’s Disease
92. The nurse explains to the lient with thyroid disease
that the thyroid gland normally produces:
a. Iodine, and TSH
b. TRH, and TSH
c. TSH, T3, and calcitonin
d. T3, T4, calcitonin
93. What will you do to know if the patient has laryngeal
nerve damage?
a. Ask the patient to speak every hour
b. Encourage the patient to vomit blood
c. Inspect paralysis on the neck
d. Ask the patient to dance
94. Immediately after thyroidectomy, what is the
PRIORITY nursing intervention of the nurse?
a. Assess for hemorrhage
b. Assess for Hypocalcemic Tetany
c. Assess for laryngeal nerve damage
d. Assess for thyroid storm
95. Which piece of equipment is most important for the
nurse to keep at the client’s bedside who had
undergone subtotal thyroidectomy?
a. Indwelling urinary catheter kit
b. Tracheostomy set
c. Scissors
b. Humidifier
96. A client with myasthenia gravis is experiencing
prolonged periods of weakness, and the physician
orders an edrophonium (Tensilon) test A test dose is
administered and the client becomes weaker. The nurse
interprets this test result as:
a. Normal
b. Positive
c. Myasthenic crisis
d. Cholinergic crisis
97. The nurse is monitoring the intracranial pressure
(ICP) of a client with a head injury and notes that the ICP
is averaging 25 mmHg. How should the nurse correctly
interpret this result?
a. The result is normal.
b. Compensation is occurring, indicating adequate brain
adaptation.
c. ICP is increased, indicating a serious compromise in
cerebral perfusion.
d. ICP is borderline in elevation, indicating the initial
stage of decompensation.
98. A nurse is performing an assessment on a client who
has a suspected spinal cord injury. Which of the
following is the priority nursing assessment?
a. Pain level
b. Mobility level
c. Respiratory status
d. Pupillary response
99. The nurse is assessing a 38-year-old client diagnosed
with multiple sclerosis. Which of the following
symptoms would the nurse expect to find?
a. Vision changes
b. Absent deep tendon reflexes
c. Tremors at rest
d. Flaccid muscles
100. A client with myasthenia gravis arrives at the
hospital emergency department in suspected crisis. The
nurse prepares to administer which medication as
prescribed if the client is in cholinergic crisis?
a. Atropine sulfate
b. Morphine sulfate
c. Pyridostigmine (Mestinon)
d. Tensilon
CARE OF CLIENTS WITH ENDOCRINE DISORDER
101. Which of the following is caused by a total lack of
endogenous insulin?
a. Metabolic alkalosis
b. Hypotension
c. Hyperosmolar hyperglycaemic nonketotic syndrome
(HHNS)
d. Diabetic Ketoacidosis
102. A patient with SIADH asks why he is on water
restriction. The appropriate response by the nurse
would be:
a. The physician has prescribed it.
b. You are not on fluid restriction. Your sodium level is
restricted.
c. Water restrictions will bring your potassium level back
to normal.
d. Your body is producing too much ADH, causing you
to reabsorb water. Limiting your water will help bring
your fluid level down and your sodium level up.
103. Which of the following is true with regards to
insulin absorption?
a. The fastest absorption occurs in the subcutaneous
tissues of the arm.
b. The nurse should rotate the injection site to prevent
subcutaneous tissue irritation.
c. Insulin are administer directly from the refrigerator.
d. Insulin injection are carefully spaced apart at least
an inch away from one another to prevent
lipodystrophy.
104. When taking the blood pressure of a client after a
parathyroidectomy, the nurse notes that the client's
hand has gone into flexion contractions. What is the
nurse’s interpretation of this observation?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypocalcemia
105. A nurse has developed a postoperative plan of care
for a client who had a thyroidectomy and formulates a
nursing diagnosis of risk for Ineffective breathing
pattern. Which of the following nursing interventions
will the nurse include in the plan of care?
a. Maintain a supine position.
b. Encourage deep breathing exercises and vigorous
coughing exercises.
c. Monitor neck circumference every 4 hours.
d. Maintain a pressure dressing on the operative site.
106. A client with hypovolemia experiences activation of
the renin-angiotensin system to maintain blood
pressure. The nurse plans care understanding that, as
part of this response, the endocrine system will increase
production and secretion of which mineralocorticoid?
a. Aldosterone
b. Adrenocorticotropic hormone
c. Cortisol
d. Glucagon
107. Addisonian Crisis is exhibited by a potentially fatal
electrolyte imbalance with which of the following?
a. Hyponatremia and Hyperkalemia
b. Hyponatremia and Hypokalemia
c. Hypernatremia and Hyperkalemia
d. Hypernatremia and Hypokalemia
108. A client has been diagnosed with Cushing’s
syndrome. The nurse would assess this client for which
of the following as expected manifestations of this
disorder?
a. Hyperkalemia and bronzed skin appearance
b. Moon facies and hirsutism
c. Hypotension and dizziness
d. Anorexia and weight loss
109. A nurse is providing discharge instructions to a
client who has Cushing’s syndrome. Which client
statement indicates that instructions related to dietary
management are understood?
a. “I can eat foods that have a lot of potassium in
them.”
b. “I will need to limit the amount of potassium in my
diet.”
c. “I am fortunate that I can eat all the salty foods I
enjoy.”
d. “I am fortunate that I do not need to follow any
special diet.”
110. A nurse is reviewing the laboratory test results for a
client with a diagnosis of Cushing’s syndrome. Which of
the following laboratory findings would the nurse expect
to note in this client?
a. A serum sodium level of 110 mEq/L
b. A potassium (K) level of 6.8 mEq/L
c. A white blood cell (WBC) count of 3000 cells/mm
d. A blood pressure reading of 90/70 mm Hg
SITUATION: Bowel perforation, gunshot wound,
perforated ulcer are one of the following causes of
peritonitis.
111. At first, symptoms of peritonitis will present the
following:
a. Diffuse pain which tends to become constant and
systemic
b. Constant pain, localized, and movement usually
aggravates it
c. Constant systemic pain
d. Constant, systemic, and with periods of diffuse pain
At first, symptoms of peritonitis, there is diffuse pain
which tends to become constant and localized, and
more intense over the site and movement usually
aggravates it. Pp 1081 Brunner 12th ed.
112. Associated manifestations of peritonitis are the
following:
a. Presence of rebound tenderness and absence of
paralytic ileus
b. Increased temperature and pulse rate, absence of
paralytic ileus
c. Rigid abdomen, presence of rebound tenderness,
decrease pulse rate
d. Increased pulse rate and temperature, rigid
abdomen
113. In this condition, intensive care often needed. As a
nurse, one of the primary nursing intervention for this
condition is?
a. to decrease the pain
b. monitor for signs of ascites
c. monitor for shock
d. advise the patient to undergo surgical treatment
114. Peritonitis can lead to what type of shock?
a. Anaphylactic
b. Cardiogenic
c. Neurogenic
d. Septic
115. Which of the following shock shares a common
pathophysiologic basis?
a. Cardiogenic and anaphylactic shock
b. Spinal and hypovolemic shock
c. Septic and neurogenic shock
d. Hypovolemic and septic shock
PATIENT WITH ACROMEGALY
116. Upon assessment of a client with acromegaly, what
will the nurse notice to the patient except?
a. Enlargement of the tongue
b. Space-shaped hands
c. Prognathism
d. Decreasing the lip and nose sizes
117. Hypersecretion of GH can lead to:
a. Glucose intolerance
b. Organoatrophy
c. Soft tissue atrophy
d. None of the above
118. The nurse reviews that patient’s chart and saw that
the physician prescribes Sandostatin (Octreotide) for
acromegaly. The nurse’ knows that the action of this
drug is for:
a. Growth hormone suppression
b. Decreasing the blood glucose level
c. Stimulating the release of growth hormone
d. Stimulates growth hormone to secrete
119. What is the administration route of Sandostatin
(Octreotide) in acromegaly patient?
a. I.V.
b. I.M.
c. I.D.
d. SubQ
120. The most common side effect of Sandostatin
(Octreotide):
a. Constipation
b. Abdominal Pain
c. Hypotension
d. Dysuria
CARE OF THE PATIENT WITH HEPATO-BILIARY
DISORDERS
121. The group of characteristics that would alert the
nurse that a client is at increased risk of developing
gallbladder disease would be female:
a. Over the age of 40, obese
b. Under the age of 40, history of high fat intake
c. Over the age of 40, low serum cholesterol level
d. Under the age of 40, family history of gallbladder
stones
122. While preparing a client for cholecystectomy, the
nurse explains that incentive spirometry will be used
after surgery
primarily to:
a.increase respiratory effectiveness.
b.eliminate the need for nasogastric intubation.
c.improve nutritional status during recovery.
d.decrease the amount of postoperative analgesia
needed.
RATIONALES: The high abdominal incision used in a
cholecystectomy interferes with respirations
postoperatively increasing the risk of atelectasis.
Therefore, incentive spirometry is used to promote lung
expansion, increase alveolar inflation, and strengthen
respiratory muscles. Incentive spirometry has no effect
on intubation, nutrition, or analgesia.
123. What do you call the stone found in the common
bile duct?
a. Cholelithiasis
b. Choledocolithtotolithiasis
c. Cholecytolithiasis
d. Choledocolithiasis
124. Which of the following nursing measures would be
most appropriate for a patient who has ascites?
a. withholding fluids
b. measuring abdominal girth
c. encouraging ambulation
d. monitoring for pedal edema
125. What causes the ascites of the patient?
a. Decreased hydrostatic pressure
b. Decreased osmotic pressure
c. Portal hypotension
d. Increased intra-abdominal pressure
126. Before paracentesis, the nurse must instruct the
patient to?
a. Drink fluids to prevent dehydration
b. Void at the rectum
c. Void to reduce the size of the bladder
d. Drink fluids so the uterus can pushed upward for
good visualization
127. After liver biopsy, the nurse must assess the
patient for signs of?
a. Hepatic encephalopathy
b. Decreasing blood pressure and increasing heart rate
c. Formation of ascites
d. Increasing BP and pulse rate
128. Which of the following is/are signs of hepatic
coma?
a. Asterixis, fetor diabeticus,
b. Fetor hepaticus, and carpopedal tremors
c. Flapping tremors, fetor hepaticus
d. Facial twitching, carpopedal spasm
129. Which of the following diet is allowed for a patient
with liver cirrhosis?
a. High protein
b. High fat
c. Low carbohydrate
d. Low protein
130. A home care nurse is visiting a client with a
diagnosis of Parkinson’s disease. The client is taking
benztropine mesylate (Cogentin) orally daily. The nurse
provides information to the spouse regarding the side
effects of this medication and tells the spouse to report
which side effect if it occurs?
a. inability to urinate
b. decrease appetite
c. shuffling gait
d. irregular bowel movement
131. A client with Addison’s disease is scheduled for
discharge after being hospitalized for an adrenal crisis.
Which statements by the client would indicate that
client teaching has been effective?
1. I have to take my steroids for 10 days.
2. I need to weigh myself daily to be sure I don’t eat too
many calories.
3. I need to call my doctor to discuss my steroid needs
before I have dental work
4. I will call the doctor if I suddenly feel profoundly
weak or dizzy.”
5. If I feel like I have the flu, I’ll carry on as usual because
this is an expected response.
6. I need to obtain and wear a Medic Alert bracelet.

a. 1,3,4,6 b. 3,4,6 c. 2,4,5 d. 2,3,4,5

132. The nurse administered neutral protamine

Hagedorn (NPH) insulin to a diabetic client at 7 a.m At
what time would the nurse expect the client to be most
at risk for a hypoglycemic reaction?
a. 10 am
b. Noon
c. 4 pm
d. 10 pm

133. The nurse is admitting a client with Guillain-Barré

syndrome to the nursing unit. The client has an
ascending paralysis to the level of the waist. Knowing
the complications of the disorder, the nurse brings
which of the following essential items into the client’s
room?
a. Nebulizer and pulse oximeter
b. Blood pressure cuff and flashlight
c. Flashlight and incentive spirometer
d. Electrocardiographic monitoring electrodes and
intubation tray

134. The nurse has instructed the family of a client with

brain attack (stroke) who has homonymous
hemianopsia about measures to help the client
overcome the deficit.
The nurse determines that the family understands the
measures to use if they state that they will:
a. Place the object in the client’s impaired field of vision
b. Discourage the client from wearing eyeglasses
c. Approach the client from the impaired field of vision
d. Remind the client to turn the head to scan the lost
visual field