SAFETY AND INFECTION CONTROL

1. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal

meningitis. Which of the following nursing measures should the nurse do FIRST?

A. Institute seizure precautions

B. Assess neurologic status
C. Place in respiratory isolation
D. Assess vital signs

2. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type
of isolation is MOST appropriate for this client?

A. Reverse isolation
B. Respiratory isolation
C. Standard precautions
D. Contact isolation

3. Several clients are admitted to an adult medical unit. The nurse would ensure airborne
precautions for a client with which of the following medical conditions?

A. A diagnosis of AIDS and cytomegalovirus

B. A positive PPD with an abnormal chest x-ray
C. A tentative diagnosis of viral pneumonia
D. Advanced carcinoma of the lung

4. Which of the following is the FIRST priority in preventing infections when providing care for
a client?

A. Handwashing
B. Wearing gloves
C. Using a barrier between client’s furniture and nurse’s bag
D. Wearing gowns and goggles

5. An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected
during a pre-employment physical. Although frightened about her diagnosis, she is anxious to
cooperate with the therapeutic regimen. The teaching plan includes information regarding the
most common means of transmitting the tubercle bacillus from one individual to another. Which
contamination is usually responsible?

A. Hands.
B. Droplet nuclei.
C. Milk products.
D. Eating utensils.
6. A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In
preparing for his admission, which of the following is the most important nursing action?

A. Order a stat admission CBC.

B. Place a urine collection bag and specimen cup at the bedside.
C. Place a cooling mattress on his bed.
D. Pad the side rails of his bed.

7. A young adult is being treated for second and third degree burns over 25% of his body and is
now ready for discharge. The nurse evaluates his understanding of discharge instructions relating
to wound care and is satisfied that he is prepared for home care when he makes which statement?

A. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath
water.”
B. “If any healed areas break open I should first cover them with a sterile dressing and then
report it.”
C. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to
bed.”
D. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”

8. An eighty five year old man was admitted for surgery for benign prostatic hypertrophy.
Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several
hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb
over the protective side rails on his bed. The most appropriate nursing intervention that will calm
an agitated client is

A. limit visits by staff.

B. encourage family phone calls.
C. position in a bright, busy area.
D. speak soothingly and provide quiet music.

9. Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the
client understands the procedure when she makes which of the following remarks the night
before the procedure?

A. She says to her husband, “Please bring me a hamburger and french fries tomorrow when
you come. I hate hospital food.”
B. “I told my daughter who is pregnant to either come to see me tonight or wait until I go
home from the hospital.”
C. “I understand it will be several weeks before all the radiation leaves my body.”
D. “I brought several craft projects to do while the radium is inserted.”

10. The nurse in charge is evaluating the infection control procedures on the unit. Which finding
indicates a break in technique and the need for education of staff?

A. The nurse aide is not wearing gloves when feeding an elderly client.
 B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go
to another department for testing.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct
client care.
D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on
strict isolation.

11. The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound.
After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After
removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves
in preparation for cleaning and redressing the wound. The most appropriate action for the charge
nurse is to:

A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to
remove the old dressing.
B. congratulate the nurse on the use of good technique.
C. discuss dressing change technique with the nurse at a later date.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of
the dirty dressing and gloves.

12. Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most
important factor to consider in this assessment is:

A. Correct illumination of the environment.

B. amount of regular exercise.
C. the resting pulse rate.
D. status of salt intake.

13. Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing
will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which
statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?

A. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
B. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal
saline.”
C. “If I question the sterility of any dressing material, I should not use it.”
D. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”

14. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which statement by the nursing assistant indicates the best
understanding of the correct protocol for blood and body fluid isolation?

A. Masks should be worn with all client contact.

B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled
items.
C. Isolation gowns are not needed.
 D. A private room is always indicated.

15. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary
personnel in the correct procedures. Which statement by the nursing assistant indicates the best
understanding of the correct protocol for blood and body fluid isolation?

A. Masks should be worn with all client contact.

B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled
items.
C. Isolation gowns are not needed.
D. A private room is always indicated.

16. The nurse is evaluating whether nonprofessional staff understand how to prevent
transmission of HIV. Which of the following behaviors indicates correct application of universal
precautions?

A. A lab technician rests his hand on the desk to steady it while recapping the needle after
drawing blood.
B. An aide wears gloves to feed a helpless client.
C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction
a tracheostomy.
D. A pregnant worker refuses to care for a client known to have AIDS.

17. Jayson, 1 year old child has a staph skin infection. Her brother has also developed the same
infection. Which behavior by the children is most likely to have caused the transmission of the
organism?

A. Bathing together.
B. Coughing on each other.
C. Sharing pacifiers.
D. Eating off the same plate.

18. Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is
being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS
transmission has been effective when the client:

A. verbalizes the role of sexual activity in spread of the disorder.

B. states he will make arrangements to drop his college classes.
C. acknowledges the need to avoid all contact sports.
D. says he will avoid close contact with his three-year-old niece.

19. Which question is least useful in the assessment of a client with AIDS?

A. Are you a drug user?

B. Do you have many sex partners?
C. What is your method of birth control?
 D. How old were you when you became sexually active?

20. Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the
hospital the day before scheduled surgery. The nurse’s
preoperative goals for Mrs. M. would include:

A. independently ambulating around the unit.

B. reading the routine preoperative education materials.
C. maneuvering safely after orientation to the room.
D. using a bedpan for elimination needs.

21. The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory
guidance. The nurse should explain that a child of this age:

A. Still depends on the parents

B. Rebels against scheduled activities
C. Is highly sensitive to criticism
D. Loves to tattle

22. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis
and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements.
The nurse should include which other topic in the teaching session?

A. Nursery schools
B.  Toilet Training
C.  Safety guidelines
D. Preparation for surgery

23. Nurse Betina should begin screening for lead poisoning when a child reaches which age?

A. 6 months
B. 12 months
C. 18 months
D. 24 months

24. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse
expects to see which of the following?

A. A reduced white blood cell count

B. A decreased platelet count
C. Shallow respirations
D. Tachypnea

25. After the nurse provides dietary restrictions to the parents of a child with celiac disease,
which statement by the parents indicates effective teaching?
 A. “Well follow these instructions until our child’s symptoms disappear.”
B. “Our child must maintain these dietary restrictions until adulthood.”
C. “Our child must maintain these dietary restrictions lifelong.”
D. “We’ll follow these instructions until our child has completely grown and developed.”

26. A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When
palpating the toddler’s fontanels, what should the nurse expects to find?

A. Closed anterior fontanel and open posterior fontanel

B. Open anterior and fontanel and closed posterior fontanel
C. Closed anterior and posterior fontanels
D. Open anterior and posterior fontanels

27. Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse
should monitor this client’s fluid intake because fluid overload may cause:

A. Cerebral edema
B. Dehydration
C. Heart failure
D. Hypovolemic shock

28. An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action
is most appropriate for this infant?

A. Encouraging the infant to hold a bottle

B. Keeping the infant on bed rest to conserve energy
C. Rotating caregivers to provide more stimulation
D. Maintaining a consistent, structured environment

29. The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes
and gets a rash when playing with brightly colored balloons, and that she recently had an allergic
reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an
allergy to:

A. Bananas
B. Latex
C. Kiwifruit
D. Color dyes

30. Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater.
What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional
intake?

A. Allow the child to feed herself

B. Use specially designed dishes for children – for example, a plate with the child’s favorite
cartoon character
 C. Only serve the child’s favorite foods
D. Allow the child to eat at a small table and chair by herself

31. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a
school-age child. What’s the smallest amount of glucose that’s considered safe and not caustic to
small veins, while also providing adequate TPN?

A. 5% glucose
B. 10% glucose
C. 15% glucose
D. 17% glucose

32. David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings
best indicates that the child is free from pain?

A. Decreased appetite
B. Increased heart rate
C. Decreased urine output
D. Increased interest in play

33. When planning care for a 8-year-old boy with Down syndrome, the nurse should:

A. Plan interventions according to the developmental level of a 7-year-old child because

that’s the child’s age
B. Plan interventions according to the developmental levels of a 5-year-old because the child
will have developmental delays
C. Assess the child’s current developmental level and plan care accordingly
D. Direct all teaching to the parents because the child can’t understand

34. Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should take
priority?

A. Prevent accidents
B. Keeping a night light on to allay fears
C. Explaining normalcy of fears about body integrity
D. Encouraging the child to dress without help

35. The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which
intervention takes top priority?

A. Changing the linens on the clients’ beds

B. Restocking the bedside supplies needed for a dressing change on the upcoming shift
C. Documenting the care provided during her shift
D. Emptying the trash cans in the assigned client room
36. Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse
should:

A. Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

B. Deliver 12 breaths/minute
C. Perform only two-person CPR
D. Use the heel of one hand for sternal compressions

37. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit.
Which nursing intervention has the highest priority?

A. Instituting droplet precautions

B. Administering acetaminophen (Tylenol)
C. Obtaining history information from the parents
D. Orienting the parents to the pediatric unit

38. Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most
important factor for the nurse to stress to the mother is:

A. Developmental readiness of the child

B. Consistency in approach
C. The mother’s positive attitude
D. Developmental level of the child’s peers

39. An infant who has been in foster care since birth requires a blood transfusion. Who is
authorized to give written, informed consent for the procedure?

A. The foster mother

B. The social worker who placed the infant in the foster home
C. The registered nurse caring for the infant
D. The nurse-manager

40. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included
in the regimen. The main reason for administering allopurinol as part of the client’s
chemotherapy regimen is to:

A. Prevent metabolic breakdown of xanthine to uric acid

B. Prevent uric acid from precipitating in the ureters
C. Enhance the production of uric acid to ensure adequate excretion of urine
D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

41. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling
abroad with her parents. The nurse knows she must put on personal protective equipment to
protect herself while providing care. Based on the mode of SARS transmission, which personal
protective should the nurse wear?
 A. Gloves
B. Gown and gloves
C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye goggles or eye shield

42. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk
adolescent. How long after the test is administered should the result be evaluated?

A. Immediately
B. Within 24 hours
C. In 48 to 72 hours
D. After 5 days

43. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months.
The nurse should advise her to include which foods in her infant’s diet?

A. Iron-rich formula and baby food

B. Whole milk and baby food
C. Skim milk and baby food
D. Iron-rich formula only

44. Gracie, the mother of a 3-month-old infant calls the clinic and states that her child has a
diaper rash. What should the nurse advice?

A. “Switch to cloth diapers until the rash is gone”

B. “Use baby wipes with each diaper change.”
C. “Leave the diaper off while the infant sleeps.”
D. “Offer extra fluids to the infant until the rash improves.”

45. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child
ingests poison, what should the parents do first?

A. Administer ipecac syrup

B. Call an ambulance immediately
C. Call the poison control center
D. Punish the child for being bad

46. A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes
priority?

A. Ineffective airway clearance related to edema

B. Disturbed body image related to physical appearance
C. Impaired urinary elimination related to fluid loss
D. Risk for infection related to epidermal disruption
47. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100
ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?

A. Worsening dyspnea
B. Gastric distension
C. Nausea and vomiting
D. Temperature of 102°F (38.9° C)

48. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe
asthma exacerbation?

A. Oxygen saturation of 95%

B. Mild work of breathing
C. Absence of intercostals or substernal retractions
D. History of steroid-dependent asthma

49. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in
recognizing possible hydrocephalus?

A. Measuring head circumference

B. Obtaining skull X-ray
C. Performing a lumbar puncture
D. Magnetic resonance imaging (MRI)

50. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What
should the nurse do to help relieve the itching?

A. Apply cool air under the cast with a blow-dryer

B. Use sterile applicators to scratch the itch
C. Apply cool water under the cast
D. Apply hydrocortisone cream under the cast using sterile applicator.
Answers and Rationales

1. Answer C. The initial therapeutic management of acute bacterial meningitis includes

isolation precautions, initiation of antimicrobial therapy and maintenance of optimum
hydration. Nurses should take necessary precautions to protect themselves and others
from possible infection.
2. Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier
protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever
direct contact with any body fluid is expected. When determining the type of isolation to
use, one must consider the mode of transmission. The hands of personnel continues to be
the principal mode of transmission for methicillin resistant staphylococcus aureus
(MRSA). Because the organism is limited to the sputum in this example, precautions are
taken if contact with the patient”s sputum is expected. A private room and BSI, along
with good hand washing techniques, are the best defense against the spread of MRSA
pneumonia.
3. Answer B. The client who must be placed in airborne precautions is the client with a
positive PPD (purified protein derivative) who has a positive x-ray for a suspicious
tuberculin lesion.
4. Answer A. Handwashing remains the most effective way to avoid spreading infection.
However, too often nurses do not practice good handwashing techniques and do not teach
families to do so. Nurses need to wash their hands before and after touching the client
and before entering the nursing bag.
5. Answer B. Hands are the primary method of transmission of the common cold. The most
frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus
is present in the air as a result of coughing, sneezing, and expectoration of sputum by an
infected person. The tubercle bacillus is not transmitted by means of contaminated food.
Contact with contaminated food or water could cause outbreaks of salmonella, infectious
hepatitis, typhoid, or cholera. The tubercle bacillus is not transmitted by eating utensils.
Some exogenous microbes can be transmitted via reservoirs such as linens or eating
utensils.
6. Answer D.  Preparing for routine laboratory studies is not as high a priority as preventing
injury and promoting safety. Preparing for routine laboratory studies is not as high a
priority as preventing injury and promoting safety. A cooling blanket must be ordered by
the physician and is usually not used unless other methods for the reduction of fever have
not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent
injury and promote safety should take precedence.
7. Answer B. Bathing or showering in the usual manner is permitted, using a mild detergent
soap such as Ivory Snow. This cleanses the wounds, especially those that are still open,
and removes dead tissue. The client is taught to report changes in wound healing such as
blister formation, signs of infection, and opening of a previously healed area. Sterile
dressings are applied until the wound is assessed and a plan of care developed. The Jobs
garment is designed to place constant pressure on the new healthy tissue that is forming
to promote adherence to the underlying structure in order to prevent hypertrophic
scarring. In order to be effective, the garment must be worn for 23 hours daily. It is
removed for wound assessment and wound care and to permit bathing. The client must be
aware that infection of the wound may occur; signs of infection, including fever, redness,
pain, warmth in and around the wound and increased or foul smelling drainage must be
reported immediately.
8. Answer D. The client needs frequent visits by the staff to orient him and to assess his
safety. Phone calls from his family will not help a client who is trying to climb over the
side rails and may even add to his danger. Putting the client in a bright, busy area would
probably add to his confusion. The environment is an important factor in the prevention
of injuries. Talking softly and providing quiet music have a calming effect on the agitated
client.
9. Answer B. The client will be on a clear liquid or very low residue diet. Hamburgers and
french fries are not allowed. People who are pregnant should not come in close contact
with someone who has internal radiation therapy. The radioactivity could possibly
damage the fetus. This statement is not true. As soon as the radiation source is removed
(probably 36 to 72 hours after insertion), the client is no longer contaminated with
radioactivity. Craft projects usually require the client to sit. The client must remain flat
with very little head elevation during the time the rods are in place.
10. Answer C. There is no need to wear gloves when feeding a client. However, universal
precautions (treating all blood and body fluids as if they are infectious) should be
observed in all situations. A client with active tuberculosis should be on respiratory
precautions.  Having the client wear a mask when leaving his private room is appropriate.
Persons with exudative lesions or weeping dermatitis should not give direct client care or
handle client-care equipment until the condition resolves. Strict isolation requires the use
of mask, gown, and gloves.
11. Answer D. Nonsterile gloves are adequate to remove the old dressing. However, the use
of sterile gloves does not put the client in danger so discussion of this can wait until later.
The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove
the old dressing. The nurse should wash her hands after removing the soiled dressing and
before donning sterile gloves to clean and dress the wound. The nurse should wash her
hands after removing the soiled dressing and before donning the sterile gloves to clean
and dress the wound. Not doing this compromises client safety and should be brought to
the immediate attention of the nurse. The staff nurse is doing two things incorrectly.
Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile
gloves does not put the client in danger so discussion of this can wait until later.
However, the nurse should wash her hands after removing the soiled dressing and before
donning sterile gloves to clean and dress the wound. Not doing this compromises client
safety and should be brought to the immediate attention of the nurse.
12. Answer A. To prevent falls, the environment should be well lighted. Night lights should
be used if necessary. Other factors to assess include removing loose scatter rugs,
removing spills, and installing handrails and grab bars as appropriate. The amount of
regular exercise is not the most important factor to assess. It is only indirectly related.
The resting pulse rate is not related to preventing falls. The salt intake is not directly
related to preventing falls.
13. Answer C.  Anything dropped on the floor is no longer sterile and should not be used.
The statement indicates lack of understanding. Anything dropped on the floor is no
longer sterile and should not be used. The statement indicates lack of understanding. If
there is ever any doubt about the sterility of an instrument or dressing, it should not be
used. The 4 X 4s should be soaked prior to donning the sterile gloves. Once the sterile
gloves touch the bottle of normal saline they are no longer sterile. This statement
indicates a need for further instruction.
14. Answer B. Masks should only be worn during procedures that are likely to cause
splashes of blood or body fluid. Gloves should be worn for all contact with blood and
body fluids, nonintact skin and mucous membranes; for handling soiled items; and for
performing venipuncture. Gowns should be worn during procedures that are likely to
cause splashes of blood or body fluids. A private room is only indicated if the client’s
hygiene is poor.
15. Answer B. Masks should only be worn during procedures that are likely to cause
splashes of blood or body fluid. Gloves should be worn for all contact with blood and
body fluids, nonintact skin and mucous membranes; for handling soiled items; and for
performing venipuncture. Gowns should be worn during procedures that are likely to
cause splashes of blood or body fluids. A private room is only indicated if the client’s
hygiene is poor.
16. Answer C. Needles that have been used to draw blood should not be recapped. If it is
necessary to recap them, an instrument such as a hemostat should be used to recap. The
hand should never be used. Gloves are not necessary when feeding, since there is no
contact with mucus membranes. Although saliva may have small amounts of HIV in it,
the virus does not invade through unbroken skin. There is no evidence in the question to
indicate broken skin. Masks and protective eye wear are indicated anytime there is great
potential for splashing of body fluids that may be contaminated with blood. Suctioning of
a tracheostomy almost always stimulates coughing, which is likely to generate droplets
that may splash the health care worker. Clients who are suctioned frequently or have had
an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is
no reason to restrict pregnant workers from caring for persons with AIDS as long as they
utilize universal precautions.
17. Answer A. Direct contact is the mode of transmission for staphylococcus. Staph is not
spread by coughing. Staph is not spread through oral secretions. Direct contact is
required. Staph is not spread through oral secretions.
18. Answer A. The AIDS virus is spread through direct contact with body fluids such as
blood and through sexual intercourse. Casual contact with other people does not pose a
risk of transmission of AIDS. Unless the client is feeling very ill, there is no need for him
to drop his college classes. Contact sports are not contraindicated unless there is a
significant chance of bleeding and direct contact with others. Casual contact with other
people does not pose a risk of transmission of AIDS. There is no need to limit casual
contact with children.
19. Answer D. Drug use is a risk factor for AIDS. Multiple sex partners is a risk factor for
AIDS. Birth control methods are important to prevent a baby from being born with the
AIDS virus. The age at which sexual activity began it not relevant as it does not usually
provide information that identifies the presence of risk factors for AIDS.
20. Answer C. Independently ambulating around the unit is not appropriate because the unit
environment can change and injury could result. Assistance is necessary because of the
client’s visual deficit. It is unlikely the client can see well enough to read the materials.
Maneuvering safely after orientation to the room is a realistic goal for a person with
impaired vision. Orienting the client to the room should help the client to move safely.
Using the bedpan is an unnecessary restriction on the client as she can be oriented to the
bathroom or to call for assistance.
21. Answer C.In a 6-year-old child, a precarious sense of self causes overreaction to
criticism and a sense of inferiority. By age 6, most children no longer depend on the
parents for daily tasks and love the routine of a schedule. Tattling is more common at age
4 to 5, by age 6, the child wants to make friends and be a friend.
22. Answer C. The nurse always should reinforce safety guidelines when teaching parents
how to care for their child. By giving anticipatory guidance the nurse can help prevent
many accidental injuries. For parents of a 9-month-old infant, it is too early to discuss
nursery schools or toilet training. Because surgery is not used gastroenteritis, this topic is
inappropriate.
23. Answer C. The nurse should start screening a child for lead poisoning at age 18 months
and perform repeat screening at age 24, 30, and 36 months. High-risk infants, such as
premature infants and formula-fed infants not receiving iron supplementation, should be
 screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at
age 24 months.
24. Answer D. 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 white blood cell or platelet counts are not specific signs
of metabolic imbalance.
25. Answer C. A patient with celiac disease must maintain dietary restrictions lifelong to
avoid recurrence of clinical manifestations of the disease. The other options are incorrect
because signs and symptoms will reappear if the patient eats prohibited foods.
26. Answer C. By age 18 months, the anterior and posterior fontanels should be closed. The
diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The
triangular posterior fontanel normally closes between ages 2 and 3 months.
27. Answer A. Because of the inflammation of the meninges, the client is vulnerable to
developing cerebral edema and increase intracranial pressure. Fluid overload won’t cause
dehydration. It would be unusual for an adolescent to develop heart failure unless the
overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid
of blood.
28. Answer D. The nurse caring for an infant with nonorganic failure to thrive should
maintain a consistent, structured environment that provides interaction with the infant to
promote growth and development. Encouraging the infant to hold a bottle would
reinforce an uncaring feeding environment. The infant should receive social stimulation
rather than be confined to bed rest. The number of caregivers should be minimized to
promote consistency of care.
29. Answer B. Children with spina bifida often develop an allergy to latex and shouldn’t be
exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely
to be allergic to latex. Some children are allergic to dyes in foods and other products but
dyes aren’t a factor in a latex allergy.
30. Answer A. The best recommendation is to allow the child to feed herself because the
child’s stage of development is the preschool period of initiative. Special dishes would
enhance the primary recommendation. The child should be offered new foods and
choices, not just served her favorite foods. Using a small table and chair would also
enhance the primary recommendation.
31. Answer B. The amount of glucose that’s considered safe for peripheral veins while still
providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient
nutritional replacement, although it’s sake for peripheral veins. Any amount above 10%
must be administered via central venous access.
32. Answer D. One of the most valuable clues to pain is a behavior change: A child who’s
pain-free likes to play. A child in pain is less likely to consume food or fluids. An
increased heart rate may indicate increased pain; decreased urine output may signify
dehydration.
33. Answer C. Nursing care plan should be planned according to the developmental age of a
child with Down syndrome, not the chronological age. Because children with Down
syndrome can vary from mildly to severely mentally challenged, each child should be
individually assessed. A child with Down syndrome is capable of learning, especially a
child with mild limitations.
34. Answer A. Accidents are the major cause of death and disability during the school-age
years. Therefore, accident prevention should take priority when teaching parents of
school-age children. Preschool (not school-age) children are afraid of the dark, have fears
concerning body integrity, and should be encouraged to dress without help (with the
exception of tying shoes).
35. Answer C. Documentation should take top priority. Documentation is the only way the
nurse can legally claim that interventions were performed. The other three options would
be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take
priority over documentation.
36. Answer D. The nurse should use the heel of one hand and compress 1” to 1½ “. The
nurse should use the heels of both hands clasped together and compress the sternum 1½
“to 2” for an adult. For a small child, two-person rescue may be inappropriate. For a
child, the nurse should deliver 20 breaths/minute instead of 12.
37. Answer A. Instituting droplet precautions is a priority for a newly admitted infant with
meningococcal meningitis. Acetaminophen may be prescribed but administering it
doesn’t take priority over instituting droplet precautions. Obtaining history information
and orienting the parents to the unit don’t take priority.
38. Answer A. If the child isn’t developmentally ready, child and parent will become
frustrated. Consistency is important once toilet training has already started. The mother’s
positive attitude is important when the child is ready. Developmental levels of children
are individualized and comparison to peers isn’t useful.
39. Answer A. When children are minors and aren’t emancipated, their parents or designated
legal guardians are responsible for providing consent for medical procedures. Therefore,
the foster mother is authorized to give consent for the blood transfusion. The social
workers, the nurse, and the nurse-manager have no legal rights to give consent in this
scenario.
40. Answer A. The massive cell destruction resulting from chemotherapy may place the
client at risk for developing renal calculi; adding allopurinol decreases this risk by
preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner
described in the other options.
41. Answer D. The transmission of SARS isn’t fully understood. Therefore, all modes of
transmission must be considered possible, including airborne, droplet, and direct contact
with the virus. For protection from contracting SARS, any health care worker providing
care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye
shield.
42. Answer C. Tuberculin skin tests of delayed hypersensitivity. If the test results are
positive, a reaction should appear in 48 to 72 hours. Immediately after the test and within
24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate
the test is too long because any reaction may no longer be visible.
43. Answer D. The American Academy of Pediatrics recommends that infants at age 5
months receive iron-rich formula and that they shouldn’t receive solid food – even baby
food – until age 6 months. The Academy doesn’t recommend whole milk until age 12
months, and skim milk until after age 2 years.
44. Answer C. Leaving the diaper off while the infant sleeps helps to promote air circulation
to the area, improving the condition. Switching to cloth diapers isn’t necessary; in fact,
 that may make the rash worse. Baby wipes contain alcohol, which may worsen the
condition. Extra fluids won’t make the rash better.
45. Answer C. Before interviewing in any way, the parents should call the poison control
center for specific directions. Ipecac syrup is no longer recommended. The parents may
have to call an ambulance after calling the poison control center. Punishment for being
bad isn’t appropriate because the parents are responsible for making the environment
safe.
46. Answer A. Initially, when a preschool client is admitted to the hospital for burns, the
primary focus is on assessing and managing an effective airway. Body image disturbance,
impaired urinary elimination, and infection are all integral parts of burn management but
aren’t the first priority.
47. Answer A. Dyspnea and other signs of respiratory distress signify fluid volume excess
(overload), which can occur quickly in a child as fluid shifts rapidly between the
intracellular and extracellular compartments. Gastric distention may suggest excessive
oral fluid intake or infection. Nausea and vomiting or an elevated temperature may
indicate a fluid volume deficit.
48. Answer D. A history of steroid-dependent asthma, a contributing factor to this client’s
high-risk status, requires the nurse to treat the situation as a severe exacerbation
regardless of the severity of the current episode. An oxygen saturation of 95%, mild work
of breathing, and absence of intercostals or substernal retractions are all normal findings.
49. Answer A. Measuring head circumference is the most important assessment technique
for recognizing possible hydrocephalus, and is a key part of routine infant screening.
Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t
appropriate.
50. Answer A. Itching underneath a cast can be relieved by directing blow-dryer, set, on the
cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under
the cast. Therefore, the client should be cautioned not to put any object down the cast in
an attempt to scratch.