Sample exam

40 items Comprehensive NCLEX review answer

key
1. Which individual is at greatest risk for
developing hypertension? A) 45 year-old African
American attorney B) 60 year-old Asian
American shop owner C) 40 year-old Caucasian
nurse D)55 year-old Hispanic teacher
The correct answer is A: 45 year-old African
American attorney The incidence of
hypertension is greater among African
Americans than other groups in the US. The
incidence among the Hispanic population is
rising.
2. A child who ingested 15 maximum strength
acetaminophen tablets 45 minutes ago is seen
in the emergency department. Which of these
orders should the nurse do first? A) Gastric
lavage PRN B) Acetylcysteine (mucomyst) for
age per pharmacy C) Start an IV Dextrose 5%
with 0.33% normal saline to keep vein open D)
Activated charcoal per pharmacy
The correct answer is A: Gastric lavage PRN
Removing as much of the drug as possible is the
first step in treatment for this drug overdose.
This is best done by gastric lavage. The next
drug to give would be activated charcoal, then
mucomyst and lastly the IV fluids.
3. Which complication of cardiac catheterization
should the nurse monitor for in the initial 24
hours after the procedure? A) angina at rest B)
thrombus formation C) dizziness D) falling blood
pressure
The correct answer is B: thrombus formation
Thrombus formation in the coronary arteries is a
potential problem in the initial 24 hours after a
cardiac catheterization. A falling BP occurs
along with hemorrhage of the insertion site
which is associated with the first 12 hours after
the procedure.
4. A client is admitted to the emergency room
with renal calculi and is complaining of
moderate to severe flank pain and nausea. The
clients temperature is 100.8 degrees
Fahrenheit. The priority nursing goal for this
client is A) Maintain fluid and electrolyte
balance B) Control nausea
C) Manage pain D) Prevent urinary tract
infection
The correct answer is C: Manage pain The
immediate goal of therapy is to alleviate the
clients pain.

5. What would the nurse expect to see while

assessing the growth of children during their
school age years? A) Decreasing amounts of
body fat and muscle mass B) Little change in
body appearance from year to year C)
Progressive height increase of 4 inches each
year D) Yearly weight gain of about 5.5 pounds
per year
The correct answer is D: Yearly weight gain of
about 5.5 pounds per year School age children
gain about 5.5 pounds each year and increase
about 2 inches in height.
6. At a community health fair the blood pressure
of a 62 year-old client is 160/96. The client
states My blood pressure is usually much
lower. The nurse should tell the client to A) go
get a blood pressure check within the next 48 to
72 hours B) check blood pressure again in 2
months C) see the health care provider
immediately D) visit the health care provider
within 1 week for a BP check
The correct answer is A: go get a blood pressure
check within the next 48 to 72 hours The blood
pressure reading is moderately high with the
need to have it rechecked in a few days. The
client states it is usually much lower. Thus a
concern exists for complications such as stroke.
However immediate check by the provider of
care is not warranted. Waiting 2 months or a
week for follow-up is too long.
7. The hospital has sounded the call for a
disaster drill on the evening shift. Which of
these clients would the nurse put first on the list
to be discharged in order to make a room
available for a new admission? A) A middle
aged client with a history of being ventilator
dependent for over 7 years and admitted with
bacterial pneumonia five days ago B) A young
adult with diabetes mellitus Type 2 for over 10
years and admitted with antibiotic induced
diarrhea 24 hours ago C) An elderly client with a
history of hypertension, hypercholesterolemia
and lupus, and was admitted with StevensJohnson syndrome that morning D) An
adolescent with a positive HIV test and
admitted for acute cellulitus of the lower leg 48
hours ago
The correct answer is A: A middle aged client
with a history of being ventilator dependent for
over 7 years and admitted with bacterial
pneumonia five days ago The best candidate for
discharge is one who has had a chronic
condition and is most familiar with their care.
This client in option A is most likely stable and
could continue medication therapy at home.
8. A client has been newly diagnosed with
hypothyroidism and will take levothyroxine

(Synthroid) 50 mcg/day by mouth. As part of

the teaching plan, the nurse emphasizes that
this medication: A) Should be taken in the
morning B) May decrease the client's energy
level C) Must be stored in a dark container D)
Will decrease the client's heart rate
The correct answer is A: Should be taken in the
morning Thyroid supplement should be taken in
the morning to minimize the side effects of
insomnia
9. A 3 year-old child comes to the pediatric
clinic after the sudden onset of findings that
include irritability, thick muffled voice, croaking
on inspiration, hot to touch, sit leaning forward,
tongue protruding, drooling and suprasternal
retractions. What should the nurse do first? A)
Prepare the child for x-ray of upper airways B)
Examine the child's throat C) Collect a sputum
specimen D) Notify the healthcare provider of
the child's status
The correct answer is D: Notify the health care
provider of the child''s status These findings
suggest a medical emergency and may be due
to epiglottises. Any child with an acute onset of
an inflammatory response in the mouth and
throat should receive immediate attention in a
facility equipped to perform intubation or a
tracheostomy in the event of further or
complete obstruction.
10. In children suspected to have a diagnosis of
diabetes, which one of the following complaints
would be most likely to prompt parents to take
their school age child for evaluation? A)
Polyphagia B) Dehydration C) Bed wetting D)
Weight loss
The correct answer is C: Bed wetting In children,
fatigue and bed wetting are the chief
complaints that prompt parents to take their
child for evaluation. Bed wetting in a school age
child is readily detected by
the parents
11. A client comes to the clinic for treatment of
recurrent pelvic inflammatory disease. The
nurse recognizes that this condition most
frequently follows which type of infection? A)
Trichomoniasis B) Chlamydia C) Staphylococcus
D) Streptococcus
The correct answer is B: Chlamydia Chlamydial
infections are one of the most frequent causes
of salpingitis or pelvic inflammatory disease.
12. An RN who usually works in a spinal
rehabilitation unit is floated to the emergency
department. Which of these clients should the
charge nurse assign to this RN? A) A middleaged client who says "I took too many diet pills"

and "my heart feels like it is racing out of my

chest." B) A young adult who says "I hear songs
from heaven. I need money for beer. I quit
drinking 2 days ago for my family. Why are my
arms and legs jerking?" C) An adolescent who
has been on pain medications for terminal
cancer with an initial assessment finding of
pinpoint pupils and a relaxed respiratory rate of
10 D) An elderly client who reports having taken
a "large crack hit" 10 minutes prior to walking
into the emergency room
The correct answer is c: An adolescent who has
been on pain medications for terminal cancer
with an initial assessment finding of pinpoint
pupils and a relaxed respiratory rate of 10
Nurses who are floated to other units should be
assigned to a client who has minimal
anticipated immediate complications of their
problem. The client in option C exhibits opoid
toxicity with the pinpoint pupils and has the
least risk of complications to occur in the near
future.
13. When teaching a client with coronary artery
disease about nutrition, the nurse should
emphasize A) Eating 3 balanced meals a day B)
Adding complex carbohydrates C) Avoiding very
heavy meals D) Limiting sodium to 7 gms per
day
The correct answer is C: Avoiding very heavy
meals Eating large, heavy meals can pull blood
away from the heart for digestion and is
dangerous for the client with coronary artery
disease.
14. Which of these findings indicate that a
pump to deliver a basal rate of 10 ml per hour
plus PRN for pain break through for morphine
drip is not working? A) The client complains of
discomfort at the IV insertion site B) The client
states "I just can't get relief from my pain." C)
The level of drug is 100 ml at 8 AM and is 80 ml
at noon D) The level of the drug is 100 ml at 8
AM and is 50 ml at noon
The correct answer is C: The level of drug is 100
ml at 8 AM and is 80 ml at noon The minimal
dose of 10 ml per hour which would be 40 ml
given in a 4 hour period. Only 60 ml should be
left at noon. The pump is not functioning when
more than expected medicine is left in the
container.
15. The nurse is speaking at a community
meeting about personal responsibility for health
promotion. A participant asks about chiropractic
treatment for illnesses. What should be the
focus of the nurses response? A) Electrical
energy fields B) Spinal column manipulation C)
Mind-body balance D) Exercise of joints

The correct answer is B: Spinal column

manipulation The theory underlying chiropractic
is that interference with transmission of mental
impulses between the brain and body organs
produces diseases. Such interference is caused
by misalignment of the vertebrae. Manipulation
reduces the subluxation.
16. The nurse is performing a neurological
assessment on a client post right CVA. Which
finding, if observed by the nurse, would warrant
immediate attention? A) Decrease in level of
consciousness B) Loss of bladder control C)
Altered sensation to stimuli D) Emotional lability
The correct answer is A: Decrease in level of
consciousness A further decrease in the level of
consciousness would be indicative of a further
progression of the CVA.
17. A child who has recently been diagnosed
with cystic fibrosis is in a pediatric clinic where
a nurse is performing an assessment. Which
later finding of this disease would the nurse not
expect to see at this time? A) Positive sweat
test B) Bulky greasy stools C) Moist, productive
cough
D) Meconium ileus
The correct answer is C: Moist, productive
cough Option c is a later sign. Noisy respirations
and a dry non-productive cough are commonly
the first of the respiratory signs to appear in a
newly diagnosed client with cystic fibrosis (CF).
The other options are the earliest findings. CF is
an inherited (genetic) condition affecting the
cells that produce mucus, sweat, saliva and
digestive juices. Normally, these secretions are
thin and slippery, but in CF, a defective gene
causes the secretions to become thick and
sticky. Instead of acting as a lubricant, the
secretions plug up tubes, ducts and
passageways, especially in the pancreas and
lungs. Respiratory failure is the most dangerous
consequence of CF.
18. The home health nurse visits a male client
to provide wound care and finds the client
lethargic and confused. His wife states he fell
down the stairs 2 hours ago. The nurse should
A) Place a call to the client's health care
provider for instructions B) Send him to the
emergency room for evaluation C) Reassure the
client's wife that the symptoms are transient D)
Instruct the client's wife to call the doctor if his
symptoms become worse
The correct answer is B: Send him to the
emergency room for evaluation This client
requires immediate evaluation. A delay in
treatment could result in further deterioration
and harm. Home care nurses must prioritize

interventions based on assessment findings

that are in the client''s best interest.
19. Which of the following should the nurse
implement to prepare a client for a KUB (Kidney,
Ureter, Bladder) radiograph test? A) Client must
be NPO before the examination B) Enema to be
administered prior to the examination C)
Medicate client with Lasix 20 mg IV 30 minutes
prior to the examination D) No special orders
are necessary for this examination
The correct answer is D: No special orders are
necessary for this examination No special
preparation is necessary for this examination.
20. The nurse is giving discharge teaching to a
client 7 days post myocardial infarction. He asks
the nurse why he must wait 6 weeks before
having sexual intercourse. What is the best
response by the nurse to this question? A) "You
need to regain your strength before attempting
such exertion." B) "When you can climb 2 flights
of stairs without
problems, it is generally safe." C) "Have a glass
of wine to relax you, then you can try to have
sex." D) "If you can maintain an active walking
program, you will have less risk."
The correct answer is B: "When you can climb 2
flights of stairs without problems, it is generally
safe." There is a risk of cardiac rupture at the
point of the myocardial infarction for about 6
weeks. Scar tissue should form about that time.
Waiting until the client can tolerate climbing
stairs is the usual advice given by health care
providers.
21. A triage nurse has these 4 clients arrive in
the emergency department within 15 minutes.
Which client should the triage nurse send back
to be seen first? A) A 2 month old infant with a
history of rolling off the bed and has buldging
fontanels with crying B) A teenager who got a
singed beard while camping C) An elderly client
with complaints of frequent liquid brown colored
stools D) A middle aged client with intermittent
pain behind the right scapula
The correct answer is B: A teenager who got
singed a singed beard while camping This client
is in the greatest danger with a potential of
respiratory distress, Any client with singed facial
hair has been exposed to heat or fire in close
range that could have caused damage to the
interior of the lung. Note that the interior lining
of the lung has no nerve fibers so the client will
not be aware of swelling.
22. While planning care for a toddler, the nurse
teaches the parents about the expected
developmental changes for this age. Which
statement by the mother shows that she

understands the child's developmental needs?

A) "I want to protect my child from any falls." B)
"I will set limits on exploring the house." C) "I
understand the need to use those new skills."
D) "I intend to keep control over our child."
The correct answer is C: "I understand the need
to use those new skills." Erikson describes the
stage of the toddler as being the time when
there is normally an increase in autonomy. The
child needs to use motor skills to explore the
environment.
23. The nurse is preparing to administer an
enteral feeding to a client via a nasogastric
feeding tube. The most important action of the
nurse is A) Verify correct placement of the tube
B) Check that the feeding solution matches the
dietary order C) Aspirate abdominal contents to
determine the amount of last feeding remaining
in stomach D) Ensure that feeding solution is at
room temperature
The correct answer is A: Verify correct
placement of the tube Proper placement of the
tube prevents aspiration.
24. The nurse is caring for a client with a serum
potassium level of 3.5 mEq/L. The client is
placed on a cardiac monitor and receives 40
mEq KCL in 1000 ml of 5% dextrose in water IV.
Which of the following EKG patterns indicates to
the nurse that the infusions should be
discontinued? A) Narrowed QRS complex B)
Shortened "PR" interval C) Tall peaked T waves
D) Prominent "U" waves
The correct answer is C: Tall peaked T waves A
tall peaked T wave is a sign of hyperkalemia.
The health care provider should be notified
regarding discontinuing the medication.
25. A nurse prepares to care for a 4 year-old
newly admitted for rhabdomyosarcoma. The
nurse should alert the staff to pay more
attention to the function of which area of the
body? A) All striated muscles B) The cerebellum
C) The kidneys D) The leg bones
The correct answer is A: All striated muscles
Rhabdomyosarcoma is the most common
children''s soft tissue sarcoma. It originates in
striated (skeletal) muscles and can be found
anywhere in the body. The clue is in the middle
of the word and is myo which typically means
muscle.
26. The nurse anticipates that for a family who
practices Chinese medicine the priority goal
would be to A) Achieve harmony B) Maintain a
balance of energy C) Respect life D) Restore yin
and yang

The correct answer is D: Restore yin and yang

For followers of Chinese medicine, health is
maintained through balance between the forces
of yin and yang.
27. During an assessment of a client with
cardiomyopathy, the nurse finds that the
systolic blood pressure has decreased from 145
to 110 mm Hg and the heart rate has risen from
72 to 96 beats per minute and the client
complains of periodic dizzy spells. The nurse
instructs the client to A) Increase fluids that are
high in protein B) Restrict fluids C) Force fluids
and reassess blood pressure D) Limit fluids to
non-caffeine beverages
The correct answer is C: Force fluids and
reassess blood pressure Postural hypotension, a
decrease in systolic blood pressure of more than
15 mm Hg and an increase in heart rate of more
than 15 percent usually accompanied by
dizziness indicates volume depletion,
inadequate vasoconstrictor mechanisms, and
autonomic insufficiency.
28. A client has a Swan-Ganz catheter in place.
The nurse understands that this is intended to
measure A) Right heart function B) Left heart
function C) Renal tubule function D) Carotid
artery function
The correct answer is B: Left heart function The
Swan-Ganz catheter is placed in the pulmonary
artery to obtain information about the left side
of the heart. The pressure readings are inferred
from pressure measurements obtained on the
right side of the circulation. Right- sided heart
function is assessed through the evaluation of
the central venous pressures (CVP).
29. A nurse enters a client's room to discover
that the client has no pulse or respirations. After
calling for help, the first action the nurse should
take is A) Start a peripheral IV B) Initiate closedchest massage C) Establish an airway D) Obtain
the crash cart
The correct answer is C: Establish an airway
Establishing an airway is always the primary
objective in a cardiopulmonary arrest.
30. A client is receiving digoxin (Lanoxin) 0.25
mg. Daily. The health care provider has written
a new order to give metoprolol (Lopressor) 25
mg. B.I.D. In assessing the client prior to
administering the medications, which of the
following should the nurse report immediately
to the health care provider? A) Blood pressure
94/60 B) Heart rate 76 C) Urine output 50
ml/hour D) Respiratory rate 16
The correct answer is A: Blood pressure 94/60
Both medications decrease the heart rate.
Metoprolol affects blood pressure. Therefore,

the heart rate and blood pressure must be

within normal range (HR 60-100; systolic B/P
over 100) in order to safely administer both
medications.
31. While assessing a 1 month-old infant, which
finding should the nurse report immediately? A)
Abdominal respirations B) Irregular breathing
rate C) Inspiratory grunt D) Increased heart rate
with crying
The correct answer is C: Inspiratory grunt
Inspiratory grunting is abnormal and may be a
sign of respiratory distress in this infant.
32. The nurse practicing in a maternity setting
recognizes that the post mature fetus is at risk
due to A) Excessive fetal weight B) Low blood
sugar levels C) Depletion of subcutaneous fat D)
Progressive placental insufficiency
The correct answer is D: Progressive placental
insufficiency The placenta functions less
efficiently as pregnancy continues beyond 42
weeks. Immediate and long term effects may be
related to hypoxia.
33. The nurse is caring for a client who had a
total hip replacement 4 days ago. Which
assessment requires the nurses immediate
attention? A) I have bad muscle spasms in my
lower leg of the affected extremity. B) "I just
can't 'catch my breath' over the past few
minutes and I think I am in grave danger." C) "I
have to use the bedpan to pass my water at
least every 1 to 2 hours." D) "It seems that the
pain medication is not working as well today."
The correct answer is B: "I just can''t ''catch my
breath'' over the past few minutes and I think I
am in grave danger." The nurse would be
concerned about all of these comments.
However the most life threatening is option B.
Clients who have had hip or knee surgery are at
greatest risk for development of post operative
pulmonary embolism. Sudden dyspnea and
tachycardia are classic findings of pulmonary
embolism. Muscle spasms do not require
immediate attention. Option C may indicate a
urinary tract infection. And option D requires
further investigation and is not life threatening.
34. A client has been taking furosemide (Lasix)
for the past week. The nurse recognizes which
finding may indicate the client is experiencing a
negative side effect from the medication?

supplement is not taken. Signs and symptoms

of hypokalemia include anorexia, fatigue,
nausea, decreased GI motility, muscle
weakness, dysrhythmias.
35. A client who is pregnant comes to the clinic
for a first visit. The nurse gathers data about
her obstetric history, which includes 3 year- old
twins at home and a miscarriage 10 years ago
at 12 weeks gestation. How would the nurse
accurately document this information? A)
Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida
3 para 1 D) Gravida 3 para 2
The correct answer is C: Gravida 3 para 1
Gravida is the number of pregnancies and Parity
is the number of pregnancies that reach
viability (not the number of fetuses). Thus, for
this woman, she is now pregnant, had 2 prior
pregnancies, and 1 viable birth (twins).
36. The nurse is caring for a client with a
venous stasis ulcer. Which nursing intervention
would be most effective in promoting healing?
A) Apply dressing using sterile technique B)
Improve the client's nutrition status C) Initiate
limb compression therapy D) Begin proteolytic
debridement
The correct answer is B: Improve the client''s
nutrition status The goal of clinical management
in a client with venous stasis ulcers is to
promote healing. This only can be accomplished
with proper nutrition. The other answers are
correct, but without proper nutrition, the other
interventions would be of little help.
37. A nurse is to administer meperidine
hydrochloride (Demerol) 100 mg, atropine
sulfate (Atropisol) 0.4 mg, and promethizine
hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse
take first? A) Raise the side rails on the bed B)
Place the call bell within reach C) Instruct the
client to remain in bed D) Have the client empty
bladder
The correct answer is D: Have the client empty
bladder The first step in the process is to have
the client void prior to administering the preoperative medication. The other actions follow
this initial step in this sequence: 4 3 1 2

A) Weight gain of 5 pounds B) Edema of the

ankles C) Gastric irritability D) Decreased
appetite

38. Which of these statements best describes

the characteristic of an effective rewardfeedback system? A) Specific feedback is given
as close to the event as possible B) Staff are
given feedback in equal amounts over time C)
Positive statements are to precede a negative
statement D) Performance goals should be
higher than what is attainable

The correct answer is D: Decreased appetite

Lasix causes a loss of potassium if a

The correct answer is A: Specific feedback is

given as close to the event as possible

Feedback is most useful when given

immediately. Positive behavior is strengthened
through immediate feedback, and it is easier to
modify problem behaviors if the standards are
clearly understood.

a)initiate an IV site to begin administration of

cryoprecipitate b) type and cross-match for
possible transfusion c) monitor the client's vital
signs for the first 5 minutes d) apply ice pack
and compression dressings to the knee

39. A client with multiple sclerosis plans to

begin an exercise program. In addition to
discussing the benefits of regular exercise, the
nurse should caution the client to avoid
activities which A) Increase the heart rate B)
Lead to dehydration C) Are considered aerobic
D) May be competitive

Answer D rest, ice, compression, and elevation

(RICE) are the immediate treatments to reduce
the swelling and bleeding into the joint. These
are the priority actions for bleeding into the
joint of a client with hemophilia.

The correct answer is B: Lead to dehydration

The client must take in adequate fluids before
and during exercise periods.
40. During the evaluation of the quality of home
care for a client with Alzheimer's disease, the
priority for the nurse is to reinforce which
statement by a family member? A) At least 2
full meals a day is eaten. B) We go to a group
discussion every week at our community center.
C) We have safety bars installed in the
bathroom and have 24 hour alarms on the
doors. D) The medication is not a problem to
have it taken 3 times a day.
The correct answer is C: We have safety bars
installed in the bathroom and have 24 hour
alarms on the doors. Ensuring safety of the
client with increasing memory loss is a priority
of home care. Note all options are correct
statements. However, safety is most important
to

.
1. A child with leukemia is being discharged
after beginning chemotherapy. Which of the
following instructions will the nurse include
when teaching the parents of this child?
a) provide a diet low in protein and high
carbohydrates b) b) avoid fresh vegetables that
are not cooked or peeled c) c) notify the doctor
if the child's temperature exceeds 101 F (39C)
d) d) increase the use of humidifiers throughout
the house
Answer B fresh fruits and vegetables harbor
microorganisms, which can cause infections in
immune-compromised child. Fruits and
vegetables should either be peeled or cooked.
The physician should be notified of a
temperature above 100F, a diet low in protein is
not indicated, and humidifiers harbor fungi in
the water containers.
2. A client with hemophilia has a very swollen
knee after falling from bicycle riding. Which of
the following is the first nursing action?

3. A client and her husband are positive for the

sickle cell trait. The client asks the nurse about
chances of her children having sickle cell
disease. Which of the following is appropriate
response by the nurse?
a)one of her children will have sickle cell
disease b) only the male children will be
affected c) each pregnancy carries a 25%
chance of the child being affected d) if she had
four children, one of them would have the
disease
Answer C In autosomal recessive traits, both
parents are carriers. There is a 25% chance with
each pregnancy that a child will have the
disease.
4. An 8 year old child has been diagnosed to
have iron deficiency anemia. Which of the
following activities is most appropriate for the
child to decrease oxygen demands on the body?
a)Dancing b) playing video games c) reading a
book d) riding a bicycle
Answer C reading a book is restful activity and
can keep the child from becoming bored.
Choices a, b, and d require too much energy for
a child with anemia and can increase oxygen
demands on the body.
5. A 16 month old child diagnosed with
Kawasaki Disease (KD) is very irritable, refuses
to eat, and exhibits peeling skin on the hands
and feet. Which of the following would the nurse
interpret as the priority?
a)applying lotions to the hands and feet b)
offering foods the toddler likes c) placing the
toddler in a quiet environment d) encouraging
the parents to get some rest
Answer C One of the characteristics of children
with KD is irritability. They are often
inconsolable. Placing the child in a quiet
environment may help quiet the child and
reduce the workload of the heart. The child's
irritability takes priority over peeling of the skin.
6.Which of the following should the nurse do
first after noting that a child with Hirschsprung

disease has a fever and watery explosive

diarrhea?
a. Notify the physician immediately b.
Administer antidiarrheal medications c. Monitor
child ever 30 minutes d. Nothing, this is
characteristic of Hirschsprung disease
Answer A. For the child with Hirschsprung
disease, fever and explosive diarrhea indicate
enterocolitis, a life- threatening situation.
Therefore, the physician should be notified
immediately. Generally, because of the
intestinal obstruction and inadequate propulsive
intestinal movement, antidiarrheals are not
used to treat Hirschsprung disease. The child is
acutely ill and requires intervention, with
monitoring more frequently than every 30
minutes. Hirschsprung disease typically
presents with chronic constipation.
7. A newborns failure to pass meconium within
the first 24 hours after birth may indicate which
of the following?
a. Hirschsprung disease
b. Celiac disease
c. Intussusception
d. Abdominal wall defect
Answer A Failure to pass meconium within the
first 24 hours after birth may be an indication of
Hirschsprung disease, a congenital anomaly
resulting in mechanical obstruction due to
inadequate motility in an intestinal segment.
Failure to pass meconium is not associated with
celiac disease, intussusception, or abdominal
wall defect.
8. When assessing a child for possible
intussusception, which of the following would be
least likely to provide valuable information? a.
Stool inspection
b. Pain pattern
c. Family history
d. Abdominal palpation
Answer C. Because intussusception is not
believed to have a familial tendency, obtaining
a family history would provide the least amount
of information. Stool inspection, pain pattern,
and abdominal palpation would reveal possible
indicators of intussusception. Current, jelly-like
stools containing blood and mucus are an
indication of intussusception. Acute, episodic
abdominal pain is characteristics of
intussusception. A sausage-shaped mass may
be palpated in the right upper quadrant.

9. After teaching the parents of a preschooler

who has undergone T and A (Tonsillectomy and
Adenoidectomy) about appropriate foods to give
the child after discharge, which of the following,
if stated by the parents as appropriate foods,
indicates successful teaching? a)meatloaf and
uncooked carrots b) pork and noodle casserole
c) cream of chicken soup and orange sherbet d)
hot dog and potato chips
Answer C for the first few days after a T and A
(Tonsillectomy and Adenoidectomy), liquids and
soft foods are best tolerated by the child while
the throat is sore. Avoid hard and scratchy foods
until throat is healed.
10. A child diagnosed with tetralogy of fallot
becomes upset, crying and thrashing around
when a blood specimen is obtained. The child's
color becomes blue and respiratory rate
increases to 44 bpm. Which of the following
actions would the nurse do first? a)obtain an
order for sedation for the child b) assess for an
irregular heart rate and rhythm c) explain to the
child that it will only hurt for a short time d)
place the child in knee-to-chest position
Answer D the child is experiencing a "tet spell"
or hypoxic episode. Therefore the nurse should
place the child in a knee-to- chest position.
Flexing the legs reduces venous flow of blood
from lower extremities and reduces the volume
of blood being shunted through the
interventricular septal defect and the overriding
aorta in the child with tetralogy of fallot. As a
result, the blood then entering the systemic
circulation has higher oxygen content, and
dyspnea is reduced. Flexing the legs also
increases vascular resistance and pressure in
the left ventricle. An infant often assumes a
knee-to-chest position to relieve dyspnea. If this
position is ineffective, then the child may need
sedative. Once the child is in this position, the
nurse may assess for an irregular heart rate and
rhythm. Explaining to the child that it will only
hurt for a short time does nothing to alleviate
hypoxia.
11. Which of the following would the nurse
perform to help alleviate a child's joint pain
associated with rheumatic fever?
a)maintaining the joints in an extended
position b) applying gentle traction to the
child's affected joints c) supporting proper
alignment with rolled pillows d) using a bed
cradle to avoid the weight of bed lines on the
joints
Answer D for a child with arthritis associated
with rheumatic fever, the joints are usually so
tender that even the weight of bed linens can
cause pain. Use of the bed cradle is

recommended to help remove the weight of the

linens on painful joints. Joints need to be
maintained in good alignment, not positioned in
extension, to ensure that they remain
functional. Applying gentle traction to the joints
is not recommended because traction is usually
used to relieve muscle spasms, not typically
associated with rheumatic fever. Supporting the
body in good alignment and changing the
client's position are recommended, but these
measures are not likely to relieve pain.
12. Which of the following health teachings
regarding sickle cell crisis should be included by
the nurse?
a)it results from altered metabolism and
dehydration b) tissue hypoxia and vascular
occlusion cause the primary problems c)
increased bilirubin levels will cause
hypertension d) there are decreased clotting
factors with an increase in white blood cells
Answer B tissue hypoxia occurs as a result of
the decreased oxygen-carrying capacity of the
red blood cells. The sickled cells begin to clump
together, which leads to vascular occlusion.
13. Which of the following should the nurse
expect to note as a frequent complication for a
child with congenital heart disease?
a. Susceptibility to respiratory infection
b. Bleeding tendencies
c. Frequent vomiting and diarrhea
d. Seizure disorder
Answer A
Children with congenital heart
disease are more prone to respiratory
infections. Bleeding tendencies, frequent
vomiting, and diarrhea and seizure disorders are
not associated with congenital heart disease.
14. While assessing a newborn with cleft lip, the
nurse would be alert that which of the following
will most likely be compromised?
a. Sucking ability b. Respiratory status
c. Locomotion
d. GI function
Answer A. Because of the defect, the child will
be unable to from the mouth adequately around
nipple, thereby requiring special devices to
allow for feeding and sucking gratification.
Respiratory status may be compromised if the
child is fed improperly or during postoperative
period, Locomotion would be a problem for the
older infant because of the use of restraints. GI

functioning is not compromised in the child with

a cleft lip.
15. When providing postoperative care for the
child with a cleft palate, the nurse should
position the child in which of the following
positions?
a. Supine b. Prone c. In an infant seat d. On
the side
Answer B. Postoperatively children with cleft
palate should be placed on their abdomens to
facilitate drainage. If the child is placed in the
supine position, he or she may aspirate. Using
an infant seat does not facilitate drainage. Sidelying does not facilitate drainage as well as the
prone position
16. Which of the following nursing diagnoses
would be inappropriate for the infant with
gastroesophageal reflux (GER)?
a. Fluid volume deficit
b. Risk for aspiration
c. Altered nutrition: less than body requirements
d. Altered oral mucous membranes
Answer D GER is the backflow of gastric
contents into the esophagus resulting from
relaxation or incompetence of the lower
esophageal (cardiac) sphincter. No alteration in
the oral mucous membranes occurs with this
disorder. Fluid volume deficit, risk for aspiration,
and altered nutrition are appropriate nursing
diagnoses
17. Which of the following parameters would
the nurse monitor to evaluate the effectiveness
of thickened feedings for an infant with
gastroesophageal reflux (GER)? a. Vomiting
b. Stools
c. Uterine
d. Weight
Answer A Thickened feedings are used with
GER to stop the vomiting. Therefore, the nurse
would monitor the childs vomiting to evaluate
the effectiveness of using the thickened
feedings. No relationship exists between
feedings and characteristics of stools and
uterine. If feedings are ineffective, this should
be noted before there is any change in the
childs weight.
18. An adolescent with a history of surgical
repair for undescended testes comes to the
clinic for a sport physical. Anticipatory guidance
for the parents and adolescent would focus on

which of the following as most important?

a)the adolescent sterility b) the adolescent
future plans c) technique for monthly testicular
self- examinations d) need for a lot of
psychosocial support
Answer C Because the incidence of testicular
cancer is increased in adulthood among children
who have undescended testes. It is extremely
important to teach the adolescent how to
perform the testicular self-examination monthly.
19. When developing the teaching plan for the
parents of a 12 month old infant with
hypospadias and chordee repair, which of the
following would the nurse expect to include as
most important? a)assisting the child to
become familiar with his dressing so he will
leave them alone b) encouraging the child to
ambulate as soon as possible by using a
favorite push toy c) forcing fluids to at least 250
ml/day by offering his favorite juices d)
preventing the child from disrupting the
catheter by using soft restraints
Answer D The most important consideration for
a successful outcome of this surgery is
maintenance of the catheters or stents. A 12
month old likes to explore his environment.
Applying soft restraints will prevent the child
from disrupting the catheter.
20. A school-aged client admitted to the
hospital because of decreased urine output and
periorbital edema is diagnosed with
glomerulonephritis. Which of the following
interventions would receive the highest priority?
a)assessing vital signs every four hours b)
monitoring intake and output every 12 hours c)
obtaining daily weight measurements d)
obtaining serum electrolyte levels daily
Answer C The child will glomerulonephritis
experiences a problem with renal function that
ultimately affects fluid balance. Because weight
is the best indicator of fluid balance, obtaining
daily weights would be the highest priority.
21. When assessing a 12 year old child with
Wilm's tumor, the nurse should keep in mind
that it most important to avoid which of the
following?
a)measuring the child's chest circumference b)
palpating the child's abdomen c) placing the
child in an uprignt position d) measuring the
child's occipitofrontal circumference
Answer B The abdomen of the child with Wilm's
tumor should not be palpated because of the
danger of disseminating tumor cells. The child
with Wilm's tumor should always be handled
gently and carefully

22. When positioning the neonate with an

unrepaired myelomeningocele, which of the
following positions would be most appropriate?
a)supine the hip at 90 degree flexion b) right
side-lying position with knees flexed c) prone
with hips in abduction d) semi-fowler's position
with chest and abdomen elevated
Answer C Before surgery, the infant is kept in
the prone position to decrease tension on the
sac. This allows for optimal positioning of the
hips, knees, and feet because orthopedic
problems are common. The supine position is
unacceptable because it causes pressure on the
defect
23. A 4 year old with hydrocephalus is
scheduled to have a ventroperitoneal shunt in
the right side of the head. When developing the
child's postoperative plan of care, the nurse
would expect to place the preschooler in which
of the following positions immediately after
surgery? a)on the right side, with the foot of
the bed elevated b) on the left side, with the
head of the bed elevated c) prone with the head
of the bed elevated d) supine, with the head of
the bed flat
Answer D For at least the first 24 hours after
insertion of a ventriculoperitoneal shunt, the
child is positioned supine with the head of the
bed flat to prevent too rapid decrease in CSF
pressure. A rapid reduction in the size of the
ventricles can cause subdural hematoma.
Positioning on the operative site is to be
avoided because it places pressure on the shunt
valve, possibly blocking desired drainage of CSF.
With continued increased ICP, the child would
be positioned with the head of bed elevated to
allow gravity to aid drainage.
24. After talking with the parents of a child with
Down Syndrome, which of the following would
the nurse identify as an appropriate goal of care
of the child?
a)encouraging self-care skills in the child b)
teaching the child something new each day c)
encouraging more lenient behavior limits for the
child d) achieving age-appropriate social skills
Answer A The goal in working with mentally
challenged children is to train them to be as
independent as possible, focusing on the
developmental skills. The child may not be
capable of learning something new every day
but needs to repeat what has been taught
previously. Rather than encouraging more
lenient behavior limits, the parents need to be
strict and consistent when setting limits for the
child. Most children with Down syndrome are
unable to achieve age-appropriate social skills

due to their mental retardation. Rather, they

taught socially appropriate behaviors.

every other day d) putting powder on the skin

under the straps every day

25. When teaching an adolescent with a seizure

disorder who is receiving Valproic acid
(Depakene), which of the following would the
nurse instruct the client to report the health
care provider? a)three episodes of diarrhea b)
loss of appetite c) jaundice d) sore throat

Answer A The Pavlik harness is worn over a

diaper. Knee socks are also worn to prevent the
straps and foot and leg pieces from rubbing
directly on the skin. For maximum results, the
infant needs to wear the harness continuously.
The skin should be inspected several times a
day, not every other day, for signs of redness or
irritation. Lotions and powders are to be
avoided because they can cake and irritate the
skin. (Hip dysplasia is a condition in which the
head of the femur is improperly rested in the
acetabulum, or hip socket of the pelvis. The
characteristic manifestations are as follows:
asymmetry of the gluteal and thigh folds;
limited hip abduction in the affected hip;
apparent shortening of the femur on the
affected side (Galeazzi sign and Allis sign);
weight bearing causes titling of the pelvis
downward on the unaffected side
(Trendelenberg sign); Ortolani click (in infant
under 4 weeks of age).

Answer C A toxic effect of valproic acid

(Depakene) is liver toxicity, which may manifest
with jaundice and abdominal pain. If jaundice
occurs, the client needs to notify the health care
provider as soon as possible.
26. A hospitalized preschooler with meningitis
who is to be discharged becomes angry when
the discharge is delayed. Which of the following
play activities would be most appropriate at this
time? a)reading the child a story b) painting
with water colors c) pounding on a pegboard d)
stacking a tower of blocks
Answer C The child is angry and needs a
positive outlet for expression of feelings. An
emotionally tense child with pent-up hostilities
needs a physical activity that will release
energy and frustration. Pounding on a pegboard
offers the opportunity. Listening to a story does
not allow child to express emotions. It also
places the child in a passive role and does not
allow the child to deal with feelings in a healthy
and positive way. Activities such as paintings
and stacking a tower of blocks require
concentration and fine movements, which could
add to frustration.
27. The parents of a child tell the nurse they
feel guilty because their child almost drowned.
Which of the following remarks by the nurse
would be most appropriate? a)I can
understand why you feel guilty, but these things
happen b) tell me a bit more about your
feelings of guilt c) you should not have taken
your eyes off your child d) you really shouldn't
fell guilty; you're lucky because your child will
be alright
Answer B Guilt is a common parental
response. The parents need to be allowed to
express their feelings openly in a
nonthreatening, nonjudgmental atmosphere.
28. The nurse teaches the parents of an infant
with developmental dysplasia of the hip how to
handle their child in a Pavlik harness. Which of
the following interventions would be most
appropriate?
a)fitting the diaper under the straps b) leaving
the harness off while the infant sleeps c)
checking for the skin redness under straps

29. When assessing the development of a 15

month old child with cerebral palsy, which of
the following milestones would the nurse expect
a toddler of this age to have achieved?
a)walking up steps b) using a spoon c) copying
a circle d) putting a block in cup
Answer D Delay in achieving developmental
milestones is a characteristic of children with
cerebral palsy. A 15 month old child can put a
block in a cup. Walking up steps typically is
accomplished at 18 to 24 months. A child
usually is able to use a spoon at 18 months. The
ability to copy a circle is achieved at
approximately 3 to 4 years of age.
30. The nurse teaches the mother of a young
child with Duchenne's muscular dystrophy
about the disease and its management. Which
of the following statements by the mother
indicates successful teaching? a)my son will
probably be unable to walk independently by
the time he is 9 to 11 years old b) muscle
relaxants are effective for some children; I hope
they can help my son c) when my son is a little
bit older, he can have surgery to improve his
ability to walk d) I need to help my son be as
active as possible to prevent progression of the
disease
Answer A Muscular dystrophy is an X-linked
recessive disorder. The gene is transmitted
through female carriers to affected sons 50% of
the time. Daughters have a 50% chance of
being carriers. It is a progressive disease.
Children who are affected by this disease
usually are unable to walk independently by

age 9-11 years. There is no effective treatment

for the disease. A characteristic manifestation is
Gower's sign -- the child walks the hands up the
legs in an attempt to rise from sitting to
standing position.
31. Which of the following foods would the
nurse encourage the mother to offer to her child
with iron-deficiency anemia?
a)rice cereal, whole milk, and yellow vegetables
b) potato, peas, and chicken c) macaroni,
cheese and ham d) pudding, green vegetables
and rice
Answer B potato, peas, chicken, green
vegetables, and rice cereal contain significant
amounts of iron and therefore would be
recommended. Milk and yellow vegetables are
not good iron sources. Rice, by itself also is not
a good source of iron.
32. Because of the risks associated with
administration of factor VIII concentrate, the
nurse would report which of the following?
a)yellowing of the skin b) constipation c)
abdominal distention d) puffiness around the
eye
Answer A Because factor VIII concentrate is
derived from large pools of human plasma, the
risk of hepatitis is always present.
33. When teaching the mother of an infant who
has undergone surgical repair of a cleft lip how
to care for the suture line, the nurse
demonstrates how to remove formula and
drainage. Which of the following solutions would
the nurse use?
a)mouthwash b) providone - iodine (betadine)
solution c) a mild antiseptic solution d) halfstrength hydrogen peroxide
Answer D half-strength hydrogen peroxide is
recommended for cleansing the suture line after
cleft lip repair. The bubbling action of the
hydrogen peroxide is effective for removing
debris. Normal saline also may be used.
Mouthwashes frequently contain alcohol which
can be irritating. Povidone-iodine solution is not
used because iodine contained in the solution
can be absorbed through the skin, leading to
toxicity. A mild antiseptic solution has some
antibacterial properties but is ineffective in
removing suture-line debris.
34. Which of the following nursing diagnosis
would the nurse identify as a priority for the
infant with tracheoesophageal fistula (TEF)?
a)impaired parenting related to newborn's
illness b) risk of injury related to increased
potential for aspiration c) ineffective nutrition:
less than body requirements, related to poor

sucking ability d) ineffective breathing pattern

related to a weak diaphragm
Answer B because the blind pouch associated
with TEF fills quickly with fluids, the child is at
risk for aspiration. Children with TEF usually
develop aspiration pneumonia.
35. When the infant returns to the unit after
imperforate anus repair, the nurse places the
infant in which of the following position? a)on
the abdomen, with legs pulled up under the
body b) on the back, with legs extended
straight out c) lying on the side with hips
elevated d) lying on the back in a position of
comfort
Answer C after surgical repair for an
imperforate anus, the infant should be
positioned either supine with the legs
suspended at 90-degree angle or on either side
with the hips elevated to prevent pressure on
the perineum. A neonate who is placed on the
abdomen pulls the legs up under the body,
which puts tension on the perineum, as does
positioning the neonate with the legs extended
straight out
36. A child presents to the emergency room
with the history of ingesting a large amount of
acetaminophen. For which of the following
would the nurse assess?
a)hypertension b) frequent urination c) Right
upper quadrant pain d) headache
Answer C after ingesting a large amount of
acetaminohen, the child would complain of right
upper quadrant pain due to hepatic damage
from glutathione combining with the metabolite
of acetaminophen being broken down.
37. Which of the following statements by the
mother of an 18 month old would indicate to the
nurse that the child needs laboratory testing for
lead levels? a)my child does not always wash
after playing outside b) my child drinks 2 cups
of milk everyday c) my child has more temper
tantrums than other kids d) my child is smaller
than other kids of the same age
Answer A eating with dirty hands, especially
after playing outside, can lead to lead poisoning
because lead is often present in soil surrounding
homes. When blood levels of lead reaches 1519 mg/dL.., an investigation of the child's
environment will be initiated. Oral chelation
therapy is started when blood lead levels
reached 45 mg/dL. When they reach 70 mg/dL,
the child usually is hospitalized for intravenous
chelation therapy.

38. Which of the following statements is LEAST

accurate concerning urinary tract infections
(UTI) in children?
A)A negative urinalysis rules out UTI in children
< 2 years of age.
B)B) Children with
multiple UTIs should be evaluated for abuse. C)
Infants younger than 3 months of age with a UTI
should be admitted for intravenous antibiotics.
D) Neonatal boys are more prone to UTIs than
girls. E) Well appearing children > 3 months old
with pyelonephritis may be treated as
outpatients.
Answer A

a)I have my menses every month b) I go out to

eat with my friends c) I run three times a day
for a total of 5 hours per day d) I try to maintain
my weight around 115 lbs. for my height of 5
feet
Answer C excessive exercise, consumption of
very small amounts of food and food rituals,
amenorrhea, and excessive weight loss or
weight is below normal, lanugo, dry skin,
bradycardia, are all signs of anorexia nervosa.
41. Which of the following signs and symptoms
would observe in a child diagnosed of
laryngotracheobronchitis?

A negative urinalysis rules out UTI in children <

2 years of age. In children younger than 2years-old, a negative urinalysis does not rule
out a urinary tract infection. Up to 50% of
children with UTIs can have a false negative
urinalysis. Nitrite and leukocyte esterase
presence in urine dipstick have the highest
combined sensitivity for UTI. In addition, if both
are positive, the false positive rate is less than
4%. Most consider young girls to be at the
highest risk for UTI. This is in fact true except
for the neonatal period, when neonatal boys
actually have a higher risk than girls. Children
with UTIs are managed differently based on the
age of the child. The very young are treated
conservatively, and those under 3 months of
age are generally admitted to the hospital for IV
antibiotics. Pyelonephritis used to be commonly
managed as an inpatient, but in well appearing
children, this infection can be treated as an
outpatient with oral antibiotics.

a)predominant stridor on inspiration b)

predominant expiratory wheeze c) high fever d)
slow respiratory rate

39. A 6-year-old boy is returned to his room

following a tonsillectomy. He remains sleepy
from the anesthesia but is easily awakened. The
nurse should place the child in which of the
following positions?

43. What would cause the closure of the

Foramen ovale after the baby had been
delivered?

a. Sims. b. Side-lying. c. Supine. d. Prone.

Answer B.
Side-lying CORRECT: most effective to
facilitate drainage of secretions from the mouth
and pharynx; reduces possibility of airway
obstruction. Supine increased risk for
aspiration, would not facilitate drainage of oral
secretions Prone risk for airway obstruction
and aspiration, unable to observe the child for
signs of bleeding such as increased swallowing
Sims on side with top knee flexed and thigh
drawn up to chest and lower knee less sharply
flexed: used for vaginal or rectal examination
40. Which of the following statements indicate
that the adolescent is having an early sign of
anorexia nervosa?

Answer A Because croup cause upper airway

obstruction, inspiratory stridor is predominant
symptom
42. A child discharged with slow cerebrospinal
fluid (CSF) leak 3 days after a head injury was
sustained. What will the nurse include in the
discharge plans? a)avoid use of nonsteroidal
anti-inflammatory drugs b) turn from side to
side only c) maintain complete bed rest d)
gradually increase diet to clear liquids
Answer C most CSF leaks resolve
spontaneously. The child should be maintained
on bed rest until CSF leak stops. NSAID's may
be used. The child may assume position of
comfort. There are no dietary restrictions.

a. Decreased blood flow b. Shifting of pressures

from right side to the left side of the heart c.
Increased PO2 d. Increased in oxygen saturation
Answer B During feto-placental circulation, the
pressure in the heart is much higher in the right
side, but once breathing/crying is established,
the pressure will shift from the R to the L side,
and will facilitate the closure of Foramen Ovale.
(Note: that is why you should position the NB in
R side lying position to increase pressure in the
L side of the heart.)
44. When assessing a newborn for
developmental dysplasia of the hip, the nurse
would expect to assess which of the following?
a. Symmetrical gluteal folds b. Trendelemburg
sign c. Ortolanis sign d. Characteristic limp
Answer C Ortolanis sign is the abnormal
clicking sound when the hips are abducted. The

sound is produced when the femoral head

enters the acetabulum. Letter A is wrong
because its should be asymmetrical gluteal
fold. Letter B and C are not applicable for
newborns because they are seen in older
children.

practice B. Wearing a face mask and eye shields

is the best method C. Limiting exposure to other
children to once weekly would help D.Washing
hands and all toys frequently would be fine E.
Isolating all children with colds is the best
method

45. A newborns failure to pass meconium

within 24 hours after birth may indicate which
of the following?

Answer D Hand washing and cleaning toys that

are shared by children are the most effective
means of preventing the spread of colds and
upper respiratory tract infections during winter.
If wearing a hat during cold weather prevented
the spread of colds, then children in warm
climates, would never get sick.

a.Aganglionic Mega colon b. Celiac disease c.

Intussusception d. Abdominal wall defect
Answer A Failure to pass meconium of Newborn
during the first 24 hours of life may indicate
Hirschsprung disease or Congenital Aganglionic
Megacolon, an anomaly resulting in mechanical
obstruction due to inadequate motility in an
intestinal segment. B, C, and D are not
associated in the failure to pass meconium of
the newborn.
46. A 13-year-old girl appears at your office at
5:05 PM for a 3:30 PM appointment scheduled
for the day before. Her mother tells you that the
girl has been limping for a couple of weeks and
has much knee pain. She has been afebrile,
does not recall being hit in the knee or leg, and
has not had any illnesses recently. She has
difficulty "moving her leg inward." Given the
late hour and that the workup will be done in
the emergency department, you impress the
pediatric emergency department staff by telling
them that the most likely diagnosis is one of the
following:
A. She twisted the leg trying to be on time for
the appointment yesterday B. Septic arthritis of
the hip C. Septic arthritis of the knee D. Aseptic
necrosis of the hip E. Slipped capital femoral
epiphysis
Answer E Slipped capital femoral epiphysis
typically presents in girls aged 11 to 13 years
and boys aged 13 to 15 years who are obese. It
is most common in blacks. Although a slipped
capital femoral epiphysis can produce pain
localized to the groin area, it often presents as
knee pain, especially on the board examination.
Internal rotation is difficult. If you were to
suggest an x-ray, anteroposterior and frog
lateral x-rays of the pelvis would be the way to
go.
47. You are in your office late one cold winter
evening, seeing a pair of siblings who have a
cold and cough. The mother and paternal
grandmother are there. The grandmother notes
that the best way to prevent the spread of colds
is by wearing a wool hat at all times. What
should you say? A.Agree and pull out a cartoon
with the trademarked hats promoting your

48. A 12-year-old boy who is at the 90th

percentile for weight complains of slight pain in
the right thigh and knee for about a month. His
complains are made worse by physical activity
and he has a mild limp. He has no history of
recent infections or trauma. Physical
examination reveals a slight decrease in
internal rotation of the right hip. There is mild
right-sided metaphyseal osteopenia on
radiograph. Of the following, which would be
the MOST likely diagnosis in this boy? A)
Transient synovitis B) Septic arthritis C)
Osteomyelitis D) Slipped capital femoral
epiphysis E) Legg-Calve-Perthes disease
ANSWER D
Slipped Capital Femoral Epiphysis occurs as the
result of acute or repetitive microtrauma to a
probable abnormal femoral growth plate. It is
unilateral in 40%-80% of cases and occurs
during or just prior to the adolescent growth
spurt (age 10 to 13 years). It is more commonly
seen in boys and in very obese and/or very tall
adolescents. Onset prior to age 10 years may
indicate an underlying endocrine problem such
as hypothyroidism. The clinical presentation is a
limp with pain related to the hip joint. There
may be some shortening of the involved limb,
and internal rotation is limited. Biplanar
radiographs or computed tomographic scans
will establish the diagnosis. Mild
demineralization of the metaphysis on the
involved side is often associated.
49. A male infant weighing 3 kg is born via
spontaneous vaginal delivery at 37 weeks
gestation. His Apgar score is 6/9 at 1 and 5
minutes. The patient is in no apparent distress.
Physical examination reveals no anus. What is
the most appropriate initial step in this patients
management? (A)Colostomy (B) Continued
observation for 24 hours (C) Intubation and
mechanical ventilation (D) Magnetic resonance
imaging (MRI) of the abdomen and pelvis (E)
Posterior sagittal anorectoplasty

Answer B Continued observation for 24 hours.

The patient should be observed for delayed
passage of meconium, as this can be normal up
to 48 hours of life. If delayed beyond this
period, meconium ileus, meconium plug,
imperforate anus, or Hirschsprungs disease
should be considered. Evaluation of imperforate
anus should include inspection for drainage of
meconium through a fistula to the perineum or
the urinary tract because this significantly alters
treatment.1 Specifically, fistulae occur with low
termination of the colon/rectum, which can be
managed definitively with anorectoplasty.
Absence of a fistula significantly increases the
likelihood of a high defect imperforate anus,
which can be managed with colostomy and
subsequent contrast imaging of the distal
colon/rectum, followed by definitive repair at a
few months of age. Some surgeons obtain a
cross-table lateral abdominal radiograph (not
MRI) to determine where the terminal
colon/rectum lies in relation to the perineum,
but this approach is unnecessary and is not
widely practiced. Ultrasonography and
radiography are required to rule out VACTERL
association, but there is no need for MRI.
Intubation and mechanical ventilation are not
indicated in this case.
50. A previously healthy 5-year-old girl presents
to the ED with her parents with a temperature
of 100.8F (38.2C) and a 2-day history of
decreased appetite and persistent vague
abdominal pain withtenderness in the midabdomen and right lower quadrant. Her parents
report that she has had no appetite and felt
nauseous but has not vomited. Laboratory
results are unremarkable except for a white
blood cell count of 16,000 cells/mL (normal,
4500 11,000 cells/mL). Ultrasound of the
abdomen and pelvis is inconclusive, and the
patient is admitted to the hospital for
observation. Eighteen hours into her hospital
stay, she passes copious amounts of bloody
stool. She remains hemodynamically stable with
normal vital signs and no change in her
abdominal pain. What is this patients most
likely diagnosis? (A)Appendicitis

another possible diagnosis but is more common

in adults. The diagnosis of Meckels diverticulitis
can be confirmed by 99mTc-pertechnetate scan,
which detects heterotopic gastric mucosa or
pancreatic tissue within the diverticulum.
Meckels diverticula are usually completely
asymptomatic, but resection is necessary when
complications develop. Colonic arteriovenous
malformations can cause GI hemorrhage in
children but are much less common than
Meckels diverticula. Appendicitis is common in
children but very rarely causes hemorrhage.
Colonic diverticulitis and gastric stress ulcers
are exceedingly rare in children and are unlikely
in this case.
51. A nurse has just started her rounds
delivering medication. A new patient on her
rounds is a 4 year-old boy who is non- verbal.
This child does not have on any identification.
What should the nurse do? A: Contact the
provider B: Ask the child to write their name on
paper. C: Ask a co-worker about the
identification of the child. D: Ask the father who
is in the room the childs name.
Answer D
In this case you are able to determine the
name of the child by the fathers statement. You
should not withhold the medication from the
child following identification.
52. A nurse is caring for an infant that has
recently been diagnosed with a congenital heart
defect. Which of the following clinical signs
would most likely be present? A: Slow pulse
rate B: Weight gain C: Decreased systolic
pressure D: Irregular WBC lab values
Answer B
Weight gain is associated with CHF and
congenital heart deficits.

(B) Colonic arteriovenous malformation

53. A mother has recently been informed that

her child has Downs syndrome. You will be
assigned to care for the child at shift change.
Which of the following characteristics is not
associated with Downs syndrome? A: Simian
crease

(C) Colonic diverticulitis

B: Brachycephaly

(D) Gastric stress ulcer

C: Oily skin

(E) Meckels diverticulitis

D: Hypotonicity

Answer (E) Meckels diverticulitis. Hemorrhage

is the most common complication of Meckels
diverticulitis in children; therefore, this condition
should be considered in any child with
abdominal pain of unclear etiology associated
with GI hemorrhage. Intestinal obstruction is

Answer C
The skin would be dry and not oily.
54. Who among the following pediatric client
should be assessed first by the nurse?

a)the child with 2 episodes of soft stools during

the shift b) the child who had cough for the past
three days, with clear nasal discharge and is
irritable c) the child with 2 episodes of
inconsolable crying while the knees are drawn
over the abdomen and plays between the
episodes d) the child with skin rashes on his
face and trunk
Answer C - this indicates appendicitis. The
pattern of abdominal pain in appendicitis is as
follows: pain occurs for 2 to 3 hours, pain is
relieved in 2 to 3 hours, the n pain recurs and
persists. During the time that pain subsides, it is
when rupture of appendicitis may occur
unnoticed.
55. The nurse is caring for several infants who
are 2-day old. Who among these infants should
be given highest priority by the nurse?
a) a bottlefed infant who takes 1-ounce of milk
every 3 to 5 hours b) a breastfed infant who lost
0.5 ounce of his weight c) a bottlefed infant who
takes 2 to 3 ounces of milk every 2 to 4 hours d)
a breastfed infant who feeds every 2 to 4 hours
Answer A - the client experiences poor feeding
(1 ounce = 30 ml) which indicates specific
problems. The infant normally looses weight
during the first week of life and he/she usually
gains weight on the second week.
56. Which of the following can indicate leftsided heart failure in an infant?
A: fever
B: low appetite
C: increased respiratory rate
D: crying
. Answer C. Shortness of breath and
perspiration during feeding can also indicate
left-sided heart failure.
57. Which of the following is NOT part of the
triad of cystic fibrosis?
A: pancreatic enzyme deficiency
B: fever
C: high concentration of sweat electrolytes
D: COPD
Answer B. The triad of cystic fibrosis is COPD,
pancreatic enzyme deficiency, and a high
concentration of sweat electrolytes.
58. When assessing a child with a cleft palate,
the nurse is aware that the child is at risk for

more frequent episodes of otitis media due to

which of the following?
a. Lowered resistance from malnutrition
b. Ineffective functioning of the Eustachian
tubes
c. Plugging of the Eustachian tubes with food
particles
d. Associated congenital defects of the middle
ear.
Answer B Because of the structural defect,
children with cleft palate may have ineffective
functioning of their Eustachian tubes creating
frequent bouts of otitis media. Most children
with cleft palate remain well- nourished and
maintain adequate nutrition through the use of
proper feeding techniques. Food particles do not
pass through the cleft and into the Eustachian
tubes. There is no association between cleft
palate and congenial ear deformities.
59. Which of the following should the nurse
expect to note as a frequent complication for a
child with congenital heart disease?
a. Susceptibility to respiratory infection
b. Bleeding tendencies
c. Frequent vomiting and diarrhea
d. Seizure disorder
Answer A. Children with congenital heart
disease are more prone to respiratory
infections. Bleeding tendencies, frequent
vomiting, and diarrhea and seizure disorders are
not associated with congenital heart disease.
60. Which of the following should the nurse do
first after noting that a child with Hirschsprung
disease has a fever and watery explosive
diarrhea?
a. Notify the physician immediately
b. Administer antidiarrheal medications
c. Monitor child ever 30 minutes
d. Nothing, this is characteristic of Hirschsprung
disease
Answer A. For the child with Hirschsprung
disease, fever and explosive diarrhea indicate
enterocolitis, a life- threatening situation.
Therefore, the physician should be notified
immediately. Generally, because of the
intestinal obstruction and inadequate propulsive
intestinal movement, antidiarrheals are not
used to treat Hirschsprung disease. The child is

acutely ill and requires intervention, with

monitoring more frequently than every 30
minutes. Hirschsprung disease typically
presents with chronic constipation.
61. While assessing a child with pyloric stenosis,
the nurse is likely to note which of the
following? a. Regurgitation
b. Steatorrhea
c. Projectile vomiting
d. Currant jelly stools
Answer C. Projectile vomiting is a key symptom
of pyloric stenosis. Regurgitation is seen more
commonly with GER. Steatorrhea occurs in
malabsorption disorders such as celiac disease.
Currant jelly stools are characteristic of
intussusception.
62. Which of the following suggestions should
the nurse offer the parents of a 4-year-old boy
who resists going to bed at night?
a. Allow him to fall asleep in your room, then
move him to his own bed.
b. Tell him that you will lock him in his room if
he gets out of bed one more time.
c. Encourage active play at bedtime to tire
him out so he will fall asleep faster.
d. Read him a story and allow him to play
quietly in his bed until he falls asleep.
Answer D. Preschoolers commonly have fears
of the dark, being left alone especially at
bedtime, and ghosts, which may affect the
childs going to bed at night. Quiet play and
time with parents is a positive bedtime routine
that provides security and also readies the child
for sleep. The child should sleep in his own bed.
Telling the child about locking him in his room
will viewed by the child as a threat. Additionally,
a locked door is frightening and potentially
hazardous. Vigorous activity at bedtime stirs up
the child and makes more difficult to fall asleep.
63. The nurse is caring for a 4-year old with
cerebral palsy. Which nursing intervention will
help ready the child for rehabilitative services?
a. Patching one of the eyes to strengthen the
muscles b. Providing suckers and pinwheels to
strengthen tongue movement c. Providing
musical tapes to [provide auditory training d.
Encouraging play with a video game to improve
muscle coordination
Answer B The nurse can help ready the child
with cerebral palsy for speech therapy by

providing activities that help the child develop

tongue control.
64. The mother of a 3 year old with esophageal
reflux asks the nurse what she can do to lessen
the babys reflux. The nurse should tell the
mother to:
a. Feed the baby only when he is hungry b. Burp
the baby after feeding is completed c. Place the
baby in supine with head elevated d. Burp the
baby frequently throughout the feeding
Answer D Burping the baby throughout the
feeding will help prevent gastric distention that
contributes to esophageal reflux
65. The mother of a child with hemophilia asks
the nurse which over the counter medication is
suitable for her childs discomfort.
a. Advil (Ibuprofen) b. Tylenol (Acetaminophen)
c. Aspirin (acetylsalicytic acid) d. Naproxen
(Naprosyn)
Answer B The nurse should recommend
acetaminophen for the childs joint discomfort
because it will have no effect on the bleeding
time.
66. The nurse is assessing an infant with
hirschspungs disease. The nurse can expect
the infant to: a. Weight less than expected for
height and age b. Have infrequent bowel
movements c. Exhibit clubbing of fingers and
toes d. Have hyperactive deep tendon reflexes
Answer B The infant with hirschsprungs disease
will have infrequent bowel movements.
66. The nurse is to administer Digoxin Elixir to a
6-month old with a congenital heart defect. The
nurse auscultates an apical pulse rate of 100.
the nurse should:
a. Record the heart rate and call the physician
b. Record the heart rate and administer the
medication c. Administer the medication and
recheck the heart rate in 30 minutes d. Hold the
medication and recheck the heart rate in 30
minutes.
Answer B The infants apical heart rate is within
the accepted range for administering the
medication.
67. An 18-month old is scheduled for a cleft
palate repair. The usual type of restraints for
the child with cleft palate repair are:
a. Elbow restraints b. Full arm restraints c. Wrist
restraints d. Mummy restraints

Answer A The least restrictive restraint for

infant with a cleft lip and cleft palate repair is
elbow restraint.
68. An infant with tetralogy of fallot is
discharged with a prescription of lanoxin elixir.
The nurse should instruct the mother to: a.
Administer the medication using a nipple b.
Administer the medication using a calibrated
dropper in the bottle c. Administer the
medication using a plastic baby spoon d.
Administer the medication in the baby bottle
with 1oz of water
Answer B The medication should be
administered using a calibrated dropper that
comes with the medication. Other choices are
not necessary because a part or all of the
medication could be lost during administration.
69. The nurse is caring for an infant following a
cleft lip repair. While comforting the infant, the
nurse should avoid:

Prevent dehydration and reduce fever d. Liquefy

secretions and relieve laryngeal spasm
Answer D The primary reason for placing the
child with croup under a mist tent is to liquefy
secretions and relieve laryngeal spasm.
73. The nurse is caring for an 8-year old
following a routine tonsillectomy. Which finding
should be reported immediately?
a. Reluctance to swallow b. Drooling of bloodtinged saliva c. An axillary temperature of 99F
d. Respiratory stridor
Answer D Respiratory stridor is a symptom of
partail airway obstruction.choice A,B and C are
expected with a tonsillectomy.
74. A 2-year old is hospitalized with suspected
intussusception. Which finding is associated
with intussusception?

a.Holding the infant b.Offering a pacifier

c.Providing a mobile d.Offering sterile water

a. currant jelly stools b. Projectile vomiting c.

ribbonlike stools d. Palpable mass over the
flank

Answer B The nurse should avoid giving the

infant a pacifier or bottle because sucking is not
permitted.

Answer A A child with intussusception has stools

that contain blood and mucus, which are
described as currant jelly stools.

70. A 5-year old with congestive heart failure

has been receiving Digoxin (Lanoxin). Which
finding indicated that the medication is having a
desired effect.

75. A 4-year old is admitted with acute

leukemia. It will be most important to monitor
the child for:

a.Increased urinary output b.Stabilized weight

c.Improved appetite d.Increased pedal edema
Answer A Lanoxin slows and strenghtens the
contractions of the heart. An increase in urinary
output shows that the medication is having a
desired effect.
71. A 9-year old is admitted with suspected
rheumatic fever. Which finding is suggested of
polymigratory arthritis?
a. Irregular movements of the extremities and
facial grimacing b. Painless swelling over the
extensor surfaces of the joints c. Faint areas of
red demarcation ovet the back and abdomen d.
Swelling, inflammation and effusion of the joints
Answer D The child with poly migratory arthritis
will exhibit a painful and swollen joints.
72. A child with croup is placed in a cool, highhumidity tent connected to room air. The
primary purpose of the tent is to:
a. Prevent insensible water loss b. Provide a
moist environment with oxygen at 30% c.

a. Abdominal pain and anorexia b. Fatigue and

bruising c. Bleeding and pallor d. Petichiae and
mucosal ulcers
Answer C A child with leukemia has low platelet
cout which contributes to spontaneous
bleeding.
76. A 6-month old client with ventral septal
defect is receiving digitalis for regulation of his
heart rate. Which finding should be reported to
the doctor?
a. Blood pressure of 126/80 b. Blood glucose of
110mg/dl c. Heart rate of 60 bpm d. Respiratory
rate of 30 cpm
Answer C A heart rate of 60 in the baby should
be reported immediately. The dise should be
held if the heart rate is blow 100bpm. The blood
glucose, blood pressure and respirations are
within the normal limits.
77. A priority nursing diagnosis for a child being
admitted from a surgery following a
tonsillectomy is:
a. Altered nutrition b. Impaired communication
c. Risk for aspiration d. Altered urinary
elimination

Answer C The first priority should be on airway,

breathing and circulation.
78. An infant is admitted to the unit with
tetralogy of fallot. The nurse would anticipate
an order for which medication. a. Digoxin b.
Epinephrine c. Aminophyline d. Atropine
Answer A The infant with tetralogy of fallot has
four heart defects. He will be treated with
Digoxin to slow and strengthen the heart.
Epinephrine, aminophyline and atropine will
speed the heart rate and will not used in this
client.
79. In a child with suspected coarctation of the
aorta, the nurse would expect to find
A)Strong pedal pulses B) Diminishing cartoid
pulses C) Normal femoral pulses D) Bounding
pulses in the arms
Answer D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or
constriction of the descending aorta, causes
increased flow to the upper extremities
(increased pressure and pulses)
80. A client is admitted with the diagnosis of
meningitis. Which finding would the nurse
expect in assessing this client?
A)Hyperextension of the neck with passive
shoulder flexion B) Flexion of the hip and knees
with passive flexion of the neck C) Flexion of
the legs with rebound tenderness D)
Hyperflexion of the neck with rebound flexion of
the legs
Answer is B: Flexion of the hip and knees with
passive flexion of the neck. A positive
Brudzinskis signflexion of hip and knees with
passive flexion of the neck; a positive Kernigs
signinability to extend the knee to more than
135 degrees, without pain behind the knee,
while the hip is flexed usually establishes the
diagnosis of meningitis
81. A 2 year-old child has just been diagnosed
with cystic fibrosis. The child's father asks the
nurse "What is our major concern now, and
what will we have to deal with in the future?"
Which of the following is the best response?
A)"There is a probability of life-long
complications." B) "Cystic fibrosis results in
nutritional concerns that can be dealt with." C)
"Thin, tenacious secretions from the lungs are a
constant struggle in cystic fibrosis." D) "You will
work with a team of experts and also have
access to a support group that the family can
attend."
Answer C: "Thin, tenacious secretions from the
lungs are a constant struggle in cystic fibrosis."
All of the options will be concerns with cystic

fibrosis, however the respiratory threats are the

major concern in these clients. Other
information of interest is that cystic fibrosis is
an autosomal recessive disease. There is a 25%
chance that each of these parent''s pregnancies
will result in a child with systic fibrosis.
82. During an examination of a 2 year-old child
with a tentative diagnosis of Wilm's tumor, the
nurse would be most concerned about which
statement by the mother?
A) My child has lost 3 pounds in the last month.
B) Urinary output seemed to be less over the
past 2 days. C) All the pants have become tight
around the waist. D) The child prefers some
salty foods more than others.
Answer C: Clothing has become tight around
the waist Parents often recognize the increasing
abdominal girth first. This is an early sign of
Wilm''s tumor, a malignant tumor of the kidney.
83. A mother wants to switch her 9 month-old
infant from an iron-fortified formula to whole
milk because of the expense. Upon further
assessment, the nurse finds that the baby eats
table foods well, but drinks less milk than
before. What is the best advice by the nurse?
A)Change the baby to whole milk B) Add
chocolate syrup to the bottle C) Continue with
the present formula D) Offer fruit juice
frequently
Answer C Continue with the present formula
The recommended age for switching from
formula to whole milk is 12 months. Switching
to cow''s milk before the age of 1 can
predispose an infant to allergies and lactose
intolerance.
84. Which nursing action is a priority as the plan
of care is developed for a 7 year-old child
hospitalized for acute glomerulonephritis?
A)Assess for generalized edema B) Monitor for
increased urinary output C) Encourage rest
during hyperactive periods D) Note patterns of
increased blood pressure
Answer D Note patterns of increased blood
pressure Hypertension is a key assessment in
the course of the disease.
85. The nurse is preparing a 5 year-old for a
scheduled tonsillectomy and adenoidectomy.
The parents are anxious and concerned about
the child's reaction to impending surgery. Which
nursing intervention would be best to prepare
the child? A) Introduce the child to all staff the
day before surgery B) Explain the surgery 1
week prior to the procedure C) Arrange a tour
of the operating and recovery rooms D)

Encourage the child to bring a favorite toy to

the hospital
Answer B Explain the surgery 1 week prior to
the procedure A 5 year-old can understand the
surgery, and should be prepared well before the
procedure. Most of these procedures are "same
day" surgeries and do not require an overnight
stay.
86. The nurse is assessing a child for clinical
manifestations of iron deficiency anemia. Which
factor would the nurse recognize as cause for
the findings?

the area would cause difficulty to the child." C)

"Pushing on the stomach might lead to the
spread of infection." D) "Placing any pressure on
the abdomen may cause an abnormal
experience."
Answer A "Touching the abdomen could cause
cancer cells to spread." Manipulation of the
abdomen can lead to dissemination of cancer
cells to nearby and distant areas. Bathing and
turning the child should be done carefully. The
other options are similar but not the most
specific.

A)Decreased cardiac output B) Tissue hypoxia

C) Cerebral edema D) Reduced oxygen
saturation

90. A 13 year old girl is admitted to the ER with

lower right abdominal discomfort. The admitting
nursing should take which the following
measures first?

Answer B Tissue hypoxia When the hemoglobin

falls sufficiently to produce clinical
manifestations, the findings are directly
attributable to tissue hypoxia, a decrease in the
oxygen carrying capacity of the blood.

A: Administer Loritab to the patient for pain

relief. B: Place the patient in right sidelying
position for pressure relief. C: Start a Central
Line. D: Provide pain reduction techniques
without administering medication.

87. Which of the actions suggested to the RN by

the PN during a planning conference for a 10
month-old infant admitted 2 hours ago with
bacterial meningitis would be acceptable to add
to the plan of care?

Answer D Do not administer pain medication or

start a central line without MD orders.

A)Measure head circumference B) Place in

airborne isolation C) Provide passive range of
motion D) Provide an over-the-crib protective
top
Answer A Measure head circumference In
meningitis, assessment of neurological signs
should be done frequently. Head circumference
is measured because subdural effusions and
obstructive hydrocephalus can develop as a
complication of meningitis. The client will have
already been on airborne precautions and crib
top applied to bed on admission to the unit.
88. An eighteen month-old has been brought to
the emergency room with irritability, lethargy
over 2 days, dry skin and increased pulse.
Based upon the evaluation of these initial
findings, the nurse would assess the child for
additional findings of: A)Septicemia B)
Dehydration C) Hypokalemia D) Hypercalcemia
Answer B Dehydration Clinical findings
dehydration include lethargy, irritability, dry
skin, and increased pulse.
89. A nurse aide is taking care of a 2 year- old
child with Wilm's tumor. The nurse aide asks the
nurse why there is a sign above the bed that
says DO NOT PALPATE THE ABDOMEN? The best
response by the nurse would be which of these
statements? A) "Touching the abdomen could
cause cancer cells to spread." B) "Examining

91. A 6-year-old boy is returned to his room

following a tonsillectomy. He remains sleepy
from the anesthesia but is easily awakened. The
nurse should place the child in which of the
following positions?
a. Sims. b. Side-lying. c. Supine. d. Prone.
Answer B.
Side-lying CORRECT: most effective to
facilitate drainage of secretions from the mouth
and pharynx; reduces possibility of airway
obstruction. Supine increased risk for
aspiration, would not facilitate drainage of oral
secretions Prone risk for airway obstruction
and aspiration, unable to observe the child for
signs of bleeding such as increased swallowing
Sims on side with top knee flexed and thigh
drawn up to chest and lower knee less sharply
flexed: used for vaginal or rectal examination
92. Which of the following nursing diagnoses
would be inappropriate for the infant with
gastroesophageal reflux (GER)?
a. Fluid volume deficit
b. Risk for aspiration
c. Altered nutrition: less than body requirements
d. Altered oral mucous membranes
Answer D

GER is the backflow of gastric contents into the

esophagus resulting from relaxation or
incompetence of the lower esophageal (cardiac)
sphincter. No alteration in the oral mucous
membranes occurs with this disorder. Fluid
volume deficit, risk for aspiration, and altered
nutrition are appropriate nursing diagnoses
93. Which of the following foods would the
nurse encourage the mother to offer to her child
with iron-deficiency anemia?
a)rice cereal, whole milk, and yellow vegetables
b) potato, peas, and chicken c) macaroni,
cheese and ham d) pudding, green vegetables
and rice
Answer B potato, peas, chicken, green
vegetables, and rice cereal contain significant
amounts of iron and therefore would be
recommended. Milk and yellow vegetables are
not good iron sources. Rice, by itself also is not
a good source of iron.
94. Which of the following would the nurse
perform to help alleviate a child's joint pain
associated with rheumatic fever?
a)maintaining the joints in an extended
position b) applying gentle traction to the
child's affected joints c) supporting proper
alignment with rolled pillows d) using a bed
cradle to avoid the weight of bed lines on the
joints
Answer D for a child with arthritis associated
with rheumatic fever, the joints are usually so
tender that even the weight of bed linens can
cause pain. Use of the bed cradle is
recommended to help remove the weight of the
linens on painful joints. Joints need to be
maintained in good alignment, not positioned in
extension, to ensure that they remain
functional. Applying gentle traction to the joints
is not recommended because traction is usually
used to relieve muscle spasms, not typically
associated with rheumatic fever. Supporting the
body in good alignment and changing the
client's position are recommended, but these
measures are not likely to relieve pain.
95. A newborns failure to pass meconium
within the first 24 hours after birth may indicate
which of the following?
a. Hirschsprung disease
b. Celiac disease
c. Intussusception
d. Abdominal wall defect

Answer A Failure to pass meconium within the

first 24 hours after birth may be an indication of
Hirschsprung disease, a congenital anomaly
resulting in mechanical obstruction due to
inadequate motility in an intestinal segment.
Failure to pass meconium is not associated with
celiac disease, intussusception, or abdominal
wall defect.
96. Which of the following health teachings
regarding sickle cell crisis should be included by
the nurse?
a)it results from altered metabolism and
dehydration b) tissue hypoxia and vascular
occlusion cause the primary problems c)
increased bilirubin levels will cause
hypertension d) there are decreased clotting
factors with an increase in white blood cells
Answer B tissue hypoxia occurs as a result of
the decreased oxygen-carrying capacity of the
red blood cells. The sickled cells begin to clump
together, which leads to vascular occlusion.
97. When teaching the mother of an infant who
has undergone surgical repair of a cleft lip how
to care for the suture line, the nurse
demonstrates how to remove formula and
drainage. Which of the following solutions would
the nurse use?
a)mouthwash b) providone - iodine (betadine)
solution c) a mild antiseptic solution d) halfstrength hydrogen peroxide
Answer D half-strength hydrogen peroxide is
recommended for cleansing the suture line after
cleft lip repair. The bubbling action of the
hydrogen peroxide is effective for removing
debris. Normal saline also may be used.
Mouthwashes frequently contain alcohol which
can be irritating. Povidone-iodine solution is not
used because iodine contained in the solution
can be absorbed through the skin, leading to
toxicity. A mild antiseptic solution has some
antibacterial properties but is ineffective in
removing suture-line debris.
98. A nurse is caring for an infant that has
recently been diagnosed with a congenital heart
defect. Which of the following clinical signs
would most likely be present? A: Slow pulse
rate B: Weight gain C: Decreased systolic
pressure D: Irregular WBC lab values
Answer B
Weight gain is associated with CHF and
congenital heart deficits.
99. In a child with suspected coarctation of the
aorta, the nurse would expect to find

A)Strong pedal pulses B) Diminishing cartoid

pulses C) Normal femoral pulses D) Bounding
pulses in the arms

a)predominant stridor on inspiration b)

predominant expiratory wheeze c) high fever d)
slow respiratory rate

Answer D: Bounding pulses in the arms

Coarctation of the aorta, a narrowing or
constriction of the descending aorta, causes
increased flow to the upper extremities
(increased pressure and pulses)

Answer A Because croup cause upper airway

obstruction, inspiratory stridor is predominant
symptom

100. Which of the following signs and symptoms

would observe in a child diagnosed of
laryngotracheobronchitis?