1- The nurse is developing a plan of care for a client diagnosed with

Kawasaki disease. Which of the following should the nurse include

in the client's plan of care?
Obtain a 12-lead electrocardiogram
Offer soft foods and liquids
Administer aspirin, as prescribed

Kawasaki disease is an autoimmune disorder that occurs primarily in

individuals younger than five. This disease process may consequently cause
inflammation of the coronary arteries leading to aneurysms. Thus, an
electrocardiogram should be performed along with an echocardiogram. Soft
foods and liquids should be offered because of the chapping of the lips.
Fluids would be encouraged because of the fever commonly associated with
Kawasaki disease. Finally, treatment for this disease includes either
medium to high-dose aspirin or intravenous immunoglobin.

2- Monitoring the child's blood pressure is key in preventing the

client from developing hypertensive encephalopathy. This is a
significant complication associated with AGN and features the client
having hypertension, headache, dizziness, vomiting, and abdominal
discomfort.

blood pressure

Monitoring the child's blood pressure is key in preventing the client from
developing hypertensive encephalopathy. This is a significant complication
associated with AGN and features the client having hypertension,
headache, dizziness, vomiting, and abdominal discomfort.

3- The nurse is counseling a client about newly prescribed iron

supplementation. Which of the following statements should the
nurse make to the client?

"Drink a glass of orange juice with your iron supplement."

"Drink the iron elixir with a straw."
Orange juice is high in vitamin C, which will help increase iron absorption.
Also, this will make taking the supplement easier on the stomach; many say
it helps with the bad taste. If the healthcare provider orders an oral
suspension iron supplementation, the client should drink it through a straw
to avoid staining their teeth. Alternatively, if you administer the medication
to a young child who cannot drink through a straw, you can pull it up in a
syringe and squirt it into the back of their mouth behind their teeth.

4- The nurse is performing a physical assessment on a child with

suspected Kawasaki disease (KD). Which of the following
assessment findings would support this diagnosis? Select all that
apply.
strawberry tongue
fever
KD is an autoimmune disorder that occurs primarily in individuals younger
than five. This condition may cause systemic vasculitis and cardiac
abnormalities, including an aneurysm. The classic manifestations of KD
include a high fever (unresponsive to antibiotics and antipyretics), red,
cracked lips, strawberry tongue, and cervical lymphadenopathy.

5- The nurse is participating in a health fair and is educating female

adolescents on the human papillomavirus (HPV).

It would be correct for the nurse to identify that HPV is linked to the
development of
cervical cancer
HPV, particularly types 16 and 18, is strongly associated with the
development of cervical cancer. Persistent infection with these high-risk
HPV types can lead to cervical dysplasia and, if untreated, cervical cancer.
HPV has been linked to head & neck cancers as well as cervical cancer. A
vaccine is available to prevent the individual from developing both genital
warts and the cancer linked with HPV.

6- The nurse is providing cardiopulmonary resuscitation (CPR) to an

infant. Which pulse does the nurse plan to assess?
Brachial
The brachial pulse is the most accessible pulse on an infant and, therefore,
it is the site of choice. Accurate assessment of heart rate, breathing, and
color is an essential part of infant resuscitation, and the guidelines state
that heart rate may be assessed using a stethoscope, or palpating the
umbilical, brachial, or femoral pulses.

7- The nurse is assessing a client with suspected acute

glomerulonephritis (AGN). Which of the following findings would
support a diagnosis of acute glomerulonephritis? Select all that
apply.
increased serum creatinine
hematuria
Renal insufficiency is the hallmark of AGN. The client will have ↑ BUN and ↑
creatinine.

8- The nurse is assessing a client with Wilms tumor. Which of the

following would be an expected finding?
Hypertension

Hypertension is a clinical manifestation of Wilms tumor. This tumor is

located on the kidneys and causes increased renin, leading to hypertension
through sodium and water retention via the RAAS system.

9- Wilms tumor is a cancer most commonly in children under the age

of 5. These tumor cells originate from which of the following?
Renal cells
Wilms tumor, also known as nephroblastoma, is a cancer of the kidneys. It’s
tumor cells originate from renal cells.

10- The nurse is taking care of a 9-year-old boy undergoing testing

for acute myeloid leukemia (AML). She is assisting with the client's
positioning for a lumbar puncture. Which of the following positions
is appropriate?
Side lying
Side-lying (lateral recumbent) is the most appropriate lumbar puncture (LP)
position. The client's legs are flexed at the knee and pulled towards the
chest, while the upper thorax is curved forward in an almost fetal position.
A pillow may be placed under the client's head and/or between the legs.
This position will allow the healthcare provider to identify the lumbar
vertebrae and insert the needle into the subarachnoid space at the L3-4 or
L4-5 interspace. The lateral recumbent position is preferred over the
upright one because it allows for accurate cerebrospinal fluid (CSF) opening
pressure measurement. An upright or sitting position may be used for
the LP when the client's lateral position is not feasible.

11- The nurse is developing a plan of care for a child with severe
acute glomerulonephritis (AGN). Which of the following should the
nurse include in the client's plan of care? Select all that apply.
Obtain daily weights.
Monitor the client’s blood pressure closely.
Obtaining and monitoring the child's daily weight is key in determining the
child's fluid status. The weights should be obtained in the morning, after the
first void, using the same scale while the child wears the same clothing.

12- The nurse is assessing a child with impetigo. Which of the

following assessment findings would be an expected finding?
Select all that apply.
vesicular lesions
lesions with drainage
pruritus
Impetigo is a contagious bacterial infection of the skin. It presents with
lesions that start with macules transitioning to vesicles that rupture easily,
causing drainage. The exudate dries to form heavy, honey-colored crusts.

13-The nurse supervises a newly hired nurse caring for an infant

immediately following a cleft lip repair.
Which of the following actions by the newly hired nurse requires
follow-up?
Repositions the infant prone.
This action by the new nurse requires follow-up because placing the client
prone after the cleft lip surgery will irritate the suture line on the lip,
cause the client discomfort, and raise the risk of aspiration. Following
the cleft lip surgery, the infant should be placed on their back,
slightly upright, to prevent aspiration. Remember, this differs from a cleft
palate post-operative position where the child may be placed prone
following the surgical repair because, in the case of cleft palate
repair, prone positioning helps promote drainage of secretions and prevents
the tongue from falling backward and obstructing the already crowded
airway.

14- While preparing to discharge a 2-year-old newly diagnosed with

hypothyroidism, you include which of the following educational
points in your discharge teaching?
Take the thyroid medication at the same time each day.
Avoid taking the thyroid medication in the evening.
Encourage increased fluids and fibrous foods

When discharging a pediatric patient who is newly diagnosed with

hypothyroidism, it is essential to educate the parents about how to
administer thyroid medication. Taking thyroid medication in the evening
can cause insomnia. It should be taken at the same time each day, on an
empty stomach, 30 minutes before breakfast. Constipation is common in
hypothyroidism, so it is important to educate on the importance of
increasing fluids and fibrous foods.

15- A 12-year-old is diagnosed with a vaso-occlusive sickle cell crisis

and complains of severe headaches. What should be the nurse’s
initial intervention?
Assess the client’s neurologic status.

This client with sickle cell crisis has a high risk of cerebrovascular accidents
(CVA). Since the client has a severe headache, it is best to rule out a CVA
before initiating all other interventions.

16- The emergency department (ED) nurse cares for a child with
epistaxis.
Place the following actions in the order in which they need to be
performed, starting from first to last.
Have the child sit up with the neck forward or erect.
Apply continuous pressure to the tip of the nose with thumb and forefinger
for at least 10 minutes.
Apply ice or a cold cloth to the bridge of the nose if the bleeding persists.
Provide the child with a drink to wash away the taste of blood.

Evaluate the bleeding to determine the effectiveness of the interventions.

Correct sequence:
 1. The nurse should reposition the child by sitting up the child with the
neck forward or erect (not lying down). This is done first to reduce the
client's risk for aspiration.
2. The nurse should then instruct the client to apply continuous pressure
to the tip of the nose with thumb and forefinger for at least 10
minutes. This is done to help promote hemostasis.
3. If the bleeding persists, the nurse should then apply ice or a cold cloth
to the bridge of the nose. The action of the cold will promote
vasoconstriction, thereby minimizing bleeding.
4. Once the nurse has employed two interventions to stop the bleeding,
the nurse should offer the client a drink to wash away the taste of
blood. This is done before reassessing if the interventions have been
effective because the taste of blood is unpleasant to the client.
5. After implementing interventions and providing the client with sips of
water, the nurse should carefully evaluate if the client's nose is still
bleeding.

17- The nurse is preparing to assess a child with cystic fibrosis at

the outpatient clinic. The nurse anticipates that the primary
healthcare provider (PHCP) will order which routine laboratory
test?
Blood glucose
Diabetes mellitus is a common co-morbidity associated with cystic fibrosis
(CF). The damage that CF may cause to the pancreas may induce diabetes.
Thus, random blood glucose levels and quarterly hemoglobin A1C levels are
commonly ordered throughout the course of the illness. A random blood
glucose level greater than 200 mg/dL (11.1 mmol/L) [70-110 mg/dL, 4.0–
11.0 mmol/L]may suggest the presence of diabetes.

18- Which of the following images demonstrates the rash typical of

varicella?
This rash is typical of varicella. Varicella (chickenpox) is caused by
the varicella-zoster virus (VZV) of the herpes group. The outbreak clearly
shows macules, papules, and vesicles. The lesions evolve from red
macules to small papules; a clear blister develops on this base. Such an
evolution of rash has been described as a “dewdrop (vesicle) on a rose
petal (erythematous base).” Over the next several days, these blisters
rupture and then crust. The rash begins on the chest and back and then
spreads centrifugally to involve the face, scalp, and extremities. These
blisters and the fact that a patient with varicella typically has lesions in
different stages of development on the front, trunk, and extremities
help differentiate it from other common viral disease rashes.

Isolation precautions for varicella: A nurse must recognize this rash

because this disease is highly contagious, and appropriate isolation
precautions should be started. Varicella transmission occurs via contact
with aerosolized droplets from nasopharyngeal secretions or by direct
cutaneous contact with the vesicular fluid. The nurse should place the
varicella patient on airborne infection isolation (i.e., unfavorable air-flow
rooms) and contact precautions until all lesions have crusted. A person with
varicella is contagious beginning 1 to 2 days before rash onset until all the
chickenpox lesions have crusted.

19-The nurse is assessing a child with glomerulonephritis. Which

assessment finding requires follow-up by the nurse?
headache rated 9/10 on the Numerical Rating Scale
A complication of glomerulonephritis is encephalopathy caused by severe
hypertension associated with the disease process. A client's report of a
severe headache (the client rated it 9/10) should clue the nurse into
checking the client's blood pressure. The client should be monitored for this
potential complication, which can be avoided by closely monitoring the
client's blood pressure.

20- The nurse is providing teaching to the mother of an infant with a

diagnosis of heart failure. Which of the following educational points
would be helpful for optimizing feedings for this infant?
Select all that apply.

Small, frequent feedings.

Feed for a maximum of 30 minutes.
Increased calorie formula.
It is appropriate advice to feed an infant with heart failure in small, frequent
feedings. These infants will have a difficult time feeding and are working
very hard during their feeds. They will need to be paced so that they
conserve their energy and do not burn too many calories while feeding.
Small, frequent feeds are the best way to optimize their nutrition.

21- The nurse is caring for a client admitted to the medical-surgical

unit with cystic fibrosis

 History and Physical

11-year-old female with cystic fibrosis was admitted with failure to thrive
after losing 3 kilograms (6.6 pounds) over the past two weeks. This started
following a hospitalization because of pneumonia, and the client could not
regain the weight. The client's parents agreed to a short hospitalization to
collaborate with a nutritionist, intravenous (IV) fluids, and other treatment
interventions. On exam, the client is alert and completely oriented. The
client has a sunken eye appearance, very dry and flaky skin. Brittle hair
and nails were noted. Very thin appearance. No cardiac murmurs were
noted, and some rhonchi in both lung fields. Productive cough noted with
clear sputum. Bowel sounds were hyperactive in all four quadrants. The
client reported no pain.
Explanation

 Daily weights to determine if the client is responding to prescribed

treatments. These weights should occur in the morning after the
client's first void.
 Chest physiotherapy is indicated but should be done one hour
before meals. If done immediately after a meal, the client may
develop nausea and vomiting, worsening their nutritional status.
 The client should be encouraged to participate in care planning as
inquiring about their food preferences provides client-centered
care.
 The prescribed pancrelipase, a digestive enzyme used to increase
the absorption of nutrients and minerals, is administered
immediately before a meal or snack.
 Vitamin deficiencies are quite common in CF, and a prescribed
multivitamin is helpful. Snacks high in sodium (such as pretzels and
popcorn) are recommended because CF causes salt wasting through
the skin.
 Collaborating with a registered dietician is recommended to get
their expertise on how to treat their nutritional deficiencies.
22- The nurse is caring for several infants in the NICU. Which of the
following signs would the nurse recognize as indicative of heart
failure in an infant? Select all that apply.

 Tachycardia
Diaphoresis
Fatigue
Choice B is correct. Tachycardia is a sign of heart failure. The heart
is not pumping effectively, and the cardiac output is therefore
decreasing. As a result of decreased oxygen delivery to the tissues,
the heart rate increases to compensate for the decreasing cardiac
output.
 Choice C is correct. Diaphoresis is a sign of heart failure. Infants will
become sweaty in heart failure; you can notice this, especially on
their scalp, where healthy babies would not usually sweat. They are
diaphoretic because their body works hard to compensate for the
decrease in cardiac output due to heart failure.
 Choice D is correct. Fatigue is common in heart failure due to
decreased cardiac output and, thereby, reducing oxygen delivery to
the tissues. The infant's body demands more oxygen, and heart
failure makes it difficult to keep up with the demand, so they get very
fatigued.

23-The nurse is caring for an adolescent who has just been

diagnosed with diabetes. The nurse is teaching them about
administering their insulin. Their standard morning dose of insulin
includes 8 units of NPH and 8 units of regular insulin. The nurse
knows that the adolescent understands the instructions when they
say:
“I should draw up the regular insulin first.”

Regular insulin should be drawn up first. For a mixed dose of two types of
insulin, rapid or short-acting insulin should always be drawn up before the
intermediate or long-acting insulin. Regular or Novolin insulin is short-acting
insulin with an onset within 30-60 minutes and a duration of 5-8 hours.
Short-acting insulin covers the needs for meals the individual eats within 60
minutes. NPH insulin is an intermediate-acting insulin with an onset within
1-2 hours and a duration of 18-24 hours. NPH insulin covers the needs for
approximately half the day and is often combined with shorter-acting
insulin. The concern when mixing insulin is the contamination of the short-
acting insulin with longer-acting insulin if some of the NPH is accidentally
introduced into the vial of regular insulin. This could cause severe
hypoglycemia with subsequent injections from the vial of regular insulin.
These two types of insulin can be safely mixed as long as the correct order
of drawing them into the syringe is followed.

24- While reviewing congenital heart defects with a senior nurse in

the PICU, she asks you which defects have increased pulmonary
blood flow. You respond by listing which of the following?

Atrial septal defect (ASD)

Atrio ventricular canal defect
Ventricular septal defect (VSD)
An ASD is an abnormal opening between the atria. It causes an increased
flow of oxygenated blood into the right side of the heart, which therefore
increases pulmonary blood flow. An atrioventricular canal defect (AV canal)
is the incomplete fusion of the endocardial cushions leading to an open
‘canal’ between both atriums and ventricles. Oxygenated and
deoxygenated blood mix in the open canal and cause increased pulmonary
blood flow. A VSD is an opening between the two ventricles. Blood shunts
from the left ventricle where there is higher pressure and then to the right
ventricle where there is lower pressure, causing the increased pulmonary
blood flow.
25- The nurse is caring for a child with eczema. Which of the
following findings should the nurse expect? Select all that apply

Erythema
Pruritus
Papules
Erythema is the superficial reddening of the skin. This redness is one of the
most common symptoms of eczema and would be an expected assessment
finding for all types of eczema. Pruritus is severe itching of the skin. Itching
is one of the most common symptoms of eczema and would be an expected
assessment finding for all types of eczema. Papules are solid elevations of
skin with no visible fluid less than 1 cm in diameter. Although not all
patients with eczema will necessarily have papules, they are a common
assessment finding.

26-The nurse is caring for a child with nocturnal enuresis that was
not responsive to non-pharmacological modifications. The nurse
anticipates the primary healthcare provider (PHCP) to provide
which medication?

Desmopressin
Desmopressin is indicated for the treatment of diabetes insipidus and
nocturnal enuresis. This medication is a synthetic form of antidiuretic
hormone. It is theorized that this medication will cause the client to
reabsorb water, thereby decreasing nocturnal enuresis.

27- The nurse is discharging an adolescent with sickle cell disease.

Which statement should the nurse include in the teaching? Select all
that apply.
Keep a water bottle with you at school so that you can stay hydrated
Follow a high-calorie, high-protein diet
Drink extra fluids if you have to travel on an airplane
Daily aerobic exercise is recommended
Remaining hydrated is one of the most important points to stress to the
client. A vasocclusive crisis occurs due to dehydration, febrile illness, or
significant psychological stress. Avoiding these situations will help avoid a
crisis. Following a high-calorie, high-protein diet is necessary to promote
optimal nutrition. Supplementation with folic acid may also be needed.
Flying on an airplane is generally safe if the client hydrates even more
before the flight. Daily aerobic exercise (brisk walks) is allowed as it does
support cardiovascular and mental health. It is vigorous exercise that may
cause dehydration that should be discouraged. Again, hydration is key
before and during exercise.

28-While working on the pediatric floor, you are assigned a client

with impetigo. Which of the following actions do you take to prevent
the spread of this disease?

Initiate contact precautions

Clients with impetigo need to be placed on contact precautions to prevent

spreading this highly contagious disease. According to the CDC, these
precautions are “for clients who may be infected or colonized with specific
infectious agents for which additional precautions are needed to prevent
infection transmission. Contact precautions will be used for any disease in
which direct contact with the infectious organism can cause illness. This
includes impetigo and other conditions such as viral gastroenteritis, MRSA,
and scabies. Contact precautions will require a gown and gloves before
entering the room.

29-The nurse is caring for a child diagnosed with a coarctation of

the aorta who is scheduled for a surgical repair tomorrow morning.
When the nurse auscultates the child's lung sounds, the nurse notes
diffuse crackles and rales throughout the lung fields. The nurse
interprets this assessment as which of the following?

Pulmonary congestion

Crackles and rales are indicative of pulmonary congestion. Because this

child has coarctation of the aorta, there is too much blood backing up in the
lungs. It is impossible for the left side of the heart to move sufficient blood
forward working against the coarctation. This causes the back up of blood in
the lungs, and therefore the crackles and rales are indicative of pulmonary
congestion.
 30-The nurse is caring for an adolescent with hemophilia who
reports pain and joint bleeding after playing baseball. The nurse
should prioritize the client's

Bleeding.
Addressing the client's active bleeding is the priority, as the client may
develop shock if it goes untreated. Bleeding associated with hemophilia is
often found in the joint space or at the point of physical injury.

31-Which of the following medications may be prescribed to control

hypertension associated with a nephroblastoma?
Enalapril

Enalapril is an ACE inhibitor used to lower blood pressure. Since clients with
nephroblastoma are hypertensive due to increased renin levels, this
medication is commonly prescribed to decrease their blood pressure. Any
ACE inhibitor reduces blood pressure by inhibiting the formation of
angiotensin II in the renin-angiotensin-aldosterone system (RAAS), so they
are an excellent choice for treating hypertension caused by
nephroblastoma. While ACE-I's may be nephrotoxic, this is still the
recommended treatment and is therapeutic as long as the creatinine levels
are monitored closely.

32-The nurse is caring for an infant with the below tracing on the
electrocardiogram (ECG).
The nurse should plan to take which initial action? See the image
below.

Prepare a bag filled with ice and water.

This tracing reflects supraventricular tachycardia (SVT), which is concerning
because of the very high rate. The rate may be as high as 180 to 280
beats/min in infants. Characteristically, SVT does not have P-waves as they
are buried in the T-waves. Preparing a bag filled with ice and water is
essential because this may be applied to the face above the nose and
mouth for 15 to 30 seconds. If that is ineffective, another vagal maneuver
would be pressing the infant's knees to the chest for 15-30 seconds.
33-The nurse is caring for a toddler who is on digoxin for
congestive heart failure. The nurse educates the parent about the
symptoms of digoxin toxicity. Which statement by the parent would
indicate an understanding of this topic?
"I will have the primary health care provider (PHCP) assess my toddler if
vomiting occurs."
Digoxin toxicity in pediatric clients is manifested by nausea, vomiting,
bradycardia, anorexia, and dysrhythmias, with nausea and vomiting
typically being the initial presenting symptoms of increased digoxin levels
in the blood. Therefore, the parent should immediately bring the toddler to
the PHCP to assess the child's serum digoxin levels and initiate appropriate
intervention.

34-The nurse is caring for an infant with congenital heart disease.

Which of the following manifestations would indicate the infant has
a decreased cardiac output? Select all that apply.
poor feeding
irritability
lethargy
Poor feeding is often one of an infant's first signs of decreased cardiac
output. It becomes more challenging for the infant to breathe while feeding;
they often become sweaty and pale during feedings. This is a classic sign of
decreased cardiac output (Choice A). Irritability, restlessness, or lethargy
are vital signs of decreased cardiac output in the infant because of
declining blood oxygen levels (Choice B and E).

35-The nurse is caring for a client with bleeding related to

hemophilia. Which of the following assessment findings would be
expected? Select all that apply.
Joint pain
Decreased range of motion in joints
Hematuria
Epistaxis

Hemophilia is a genetic disorder that causes a factor VIII deficiency. Factor

VIII is produced by the liver and is necessary for the formation of
thromboplastin in phase I of blood coagulation. Bleeding
is commonly found in the joints (termed hemarthrosis), which causes joint
stiffness, aches, and a decreased range of motion. Hematuria is also a
clinical feature that may be evident (either grossly or by microscopy that
would be shown on a urine analysis). Epistaxis is a feature as well if trauma
to the nose occurs.

36- The nurse is caring for a family who just found out that their
newborn baby has tetralogy of Fallot. The parents state, "We can't
believe our baby is going to die!" Which of the
following statements by the nurse is most appropriate?
“Tetralogy of Fallot can be surgically repaired. Let’s talk more about what
you can expect.”
This statement does not support that the baby will die but provides factual
information about the treatment plan for the defect and leads into a more
detailed conversation about what the parents can expect. It is clear that
they do not fully understand tetralogy of Fallot (TOF) and the treatment
options, so education is very important for these parents.

37- The nurse reviews the assessment data for a child with acute
glomerulonephritis (AGN). Which of the following would be an
expected finding?
Proteinuria
Urinalysis shows red blood cells (hematuria) and protein (proteinuria) in a
client with AGN. In addition to hematuria, one of the characteristic findings
of AGN is the presence of red blood cell casts.

38- When the nurse is educating parents of young kids with

congenital heart defects, it is essential to teach them about the
early signs and symptoms of heart failure so that they can recognize
it sooner. Which of the following should the nurse emphasize as
early signs of heart failure?
Diaphoresis
Sudden weight gain
The parents of children with congenital heart defects need to be aware of
the “early” signs of heart failure, so they can report them to the healthcare
provider before it is too late. Diaphoresis (Choice A), or excessive
sweating is a common early sign of heart failure. Parents should be taught
to look out for excessive sweating, especially at rest. Sudden weight
gain (Choice B) is due to fluid retention and edema. This indicates
decreased cardiac output, increased venous congestion, and is
an early sign of heart failure.

39- Which is a common finding when assessing cardiac status in

preschool children?
Pulses are elevated when breathing in and decrease when breathing out.

This finding indicates sinus arrhythmia, a commonly encountered variation

of normal sinus rhythm. It is typically seen in children and young adults.
During respiration, intermittent vagus nerve activation occurs, which results
in beat-to-beat variations in the resting heart rate. When present, sinus
arrhythmia typically indicates good cardiovascular health. Sinus arrhythmia
is a commonly encountered finding when assessing preschool cardiac
status.

40- An eight-year-old boy diagnosed with hemophilia A is brought

into the urgent care clinic for a prolonged episode of hematemesis.
Which of the following describes this symptom?
Bloody vomit

Hematemesis is bloody vomit. This symptom is common with hemophilia

and can lead to severe complications if not treated promptly.

41-The nurse is caring for 12-year-old two days postoperative

following open heart surgery. The child has refused to participate in
physical therapy and ambulate. The nurse should initially
determine if the client is experiencing pain or discomfort.

Open heart surgery is a major operative procedure and may cause a client
significant postoperative pain. It would be appropriate for the nurse to
determine if the client is experiencing pain because untreated or
undertreated pain may cause a client to retract from activities such as
physical therapy and ambulation. These activities cause pain, and any
procedure causing pain will likely have the child demonstrate reluctance.

42-The nurse is caring for a child admitted with congestive heart

failure. Which of the following assessment findings would be
expected?
Exercise intolerance

Exercise intolerance is common for a child with heart failure because the
cardiac output cannot keep up with the demands of exercise. Fatigue may
develop and irritability from the child's inability to participate in exercise-
related activities.

43-The nurse is assessing a child with lead poisoning. The nurse

should expect which findings? Select all that apply.
Headaches
Irritability
Abdominal pain
Peripheral neuropathy

44- The pediatric nurse knows that which of the following are true
regarding aortic regurgitation in a pediatric client with complex
congenital heart disease? Select all that apply.
Aortic regurgitation increases preload in the left ventricle.
Aortic regurgitation causes decreased cardiac output.
Aortic regurgitation increases left ventricle end diastolic pressure.

45- The nurse is caring for a 1-month-old infant suspected of having

cardiac arrest. Which pulse should the nurse palpate for
assessment?
Brachial
In infants, the brachial artery is the right site to check for a pulse. This will
help determine how to proceed with the code event and if there is a return
of spontaneous circulation (ROSC). The brachial pulse is located inside of
the upper arm between the infant's elbow and shoulder.

46- The nurse is teaching a parenting class on ways to prevent burn

injuries in the home. Which of the following information should be
included? Select all that apply.
Protective guards should be installed in electrical outlets.
Adjust your hot water heater to prevent scald burn injuries.
Develop and practice a family escape plan in case of a fire.
Pot handles should be turned toward the back of the stove.
Protective guards should be placed in the outlet and furniture, if possible,
should be placed in front of electrical outlets. This prevents the child from
inserting objects into the outlet, preempting a serious electrical injury. The
hot water heater should be adjusted to 49°C (120°F) or lower to prevent
burn injuries. A fire escape plan should be developed for the home and
practiced in the event of a fire. Pot handles should be placed on the back
end of the stove with the handles turned toward the back.

47- The nurse is reviewing tetralogy of Fallot with a nursing

student. It would indicate effective teaching if the student identifies
which defects with this disorder? Select all that apply.

Ventricular septal defect (VSD)

Overriding aorta
Pulmonary artery stenosis
Concentric right ventricular hypertrophy
Tetralogy of Fallot is a congenital heart defect composed of four errors, a
ventricular septal defect (VSD) being one of them. The VSD is a hole
between the right and left ventricles, allowing the oxygenated and
deoxygenated blood to mix in, essentially one ventricle. An overriding aorta
being one of them is another feature. This means the aorta is positioned
over the VSD instead of over the left ventricle, where it should be.
Pulmonary stenosis is another feature of ToF. The pulmonary arteries are
narrowed and hardened, making it difficult for the right ventricle to pump
blood to the lungs. Right ventricular hypertrophy is one of them. This
portion of the error is actually due to another part: pulmonary stenosis.
Since these vessels are narrowed and hardened, it is difficult for the right
ventricle to pump blood through them and out to the lungs. This puts extra
work on the heart, and after some time, the muscle of the right ventricle
gets more substantial or hypertrophied due to the extra work.

48- The nurse is teaching the parents of a child diagnosed with

eczema. Which of the following information should the nurse
include? Select all that apply.
"Avoid harsh soaps and detergents."
"Wash the affected areas 4-5 times/day."
"Apply lotion immediately after bathing."
"Keep the nails trimmed short."
It is appropriate education to teach your parents to avoid using harsh soaps
and detergents. This can irritate and exacerbate eczema. Common irritants
include soaps, detergents, perfumes, cosmetics, jewelry, and fragrances.
Applying lotion immediately after baths will help the client to keep moisture
over the affected areas and decrease the itching and irritation associated
with eczema. Keeping nails short is a very important piece of education for
a child diagnosed with eczema. Their skin will be very itchy, but we must
teach them how to control this itching and not cause further irritation due
to scratching. Excessive scratching may cause the skin to break, triggering
a secondary infection such as cellulitis.

49- The nurse is caring for a child experiencing multiple

hypercyanotic episodes associated with tetralogy of Fallot. Which
medication should the nurse anticipate from the primary healthcare
provider (PHCP)?
Morphine
Morphine, for some unknown reason, is a medication utilized for refractory
hypercyanotic episodes. It is theorized that this medication's sedative effect
will calm the child and decrease the oxygen demand.
50- The nurse is caring for a child experiencing an adrenal crisis.The
nurse has established a peripheral vascular access device and
should be prepared to administer intravenous Select all that apply.
5% dextrose with 0.9% saline.
hydrocortisone.
An adrenal crisis is a medical emergency for both an adult and a child.
Remember, you need to add the treatment in an adrenal crisis (Addisonian
crisis). The immediate treatment for a client in an adrenal crisis is replacing
the corticosteroid via intravenous (IV) hydrocortisone. The treatment goal
of administering IV hydrocortisone is to increase the low glucose levels and
retain some of the fluid and sodium. The second essential treatment is
administering IV fluids of 5% dextrose with 0.9% saline. The 5% dextrose
with 0.9% saline will raise the glucose (D5) and circulating volume (0.9%
saline). Giving D5W alone would be detrimental as the water will lower
serum sodium levels.

51- The nurse is caring for a child who is lethargic and with a
capillary blood glucose of 46 mg/dL (2.55 mmol/L) [70-110 mg/dL,
4.0–11.0 mmol/L]. Which essential action should the nurse take?
Administer prescribed glucagon SubQ
The client is lethargic and hypoglycemic. This is quite concerning and calls
for the nurse to immediately administer a parenteral treatment (either
glucagon SubQ/IM) or Dextrose 50% via intravenous push (IVP). While this
blood glucose may respond to mouth (PO) foods and fluids, the
client is lethargic and should not be fed because of the risk of
aspiration.

52- The nurse is developing a plan of care for a 9-year-old child with
a vaso-occlusive crisis (VOC) related to sickle cell anemia (SCA).
Which of the following should the nurse include in the child's plan of
care? Select all that apply.
Obtain a prescription for patient-controlled analgesia
Perform frequent pain assessments
Plan activities with frequent rest periods
Obtaining a prescription for a PCA is an effective intervention for a client
experiencing a vaso-occlusive crisis (VOC) because PCAs give them
autonomy in their pain control. PCAs can be used as early as age 7. Opioids
are preferred in managing pain for a client with a VOC and are
advantageous because they can be administered intravenously, orally, or
intranasally. Effective pain control is the cornerstone of the management of
a VOC. This, coupled with frequent pain assessments, are essential nursing
actions. Additionally, the anemia may cause the child to experience fatigue.
The nurse should plan activities with frequent rest breaks because, during a
VOC, the client experiences significant fatigue. Also, excessive physical
activity may make the pain worse.

53- The emergency department nurse assesses a 3-day-old newborn

brought in by the mother. The mother states, "My baby is always so
sweaty and hot and doesn't want to eat! I think something is
wrong." The nurse cannot palpate a femoral pulse but notes +3
brachial pulses. Which congenital heart defect does the nurse
suspect?

Coarctation of the aorta (COA)

Based on the assessment findings, the infant most likely has a coarctation
of the aorta. In this defect, a stricture in the aorta prevents blood flow
from the left ventricle. Coarctation of the aorta usually occurs beyond the
blood vessels that branch off to the upper body but before the blood
vessels that lead to the lower body. Therefore, the blood flow to the upper
body is abundant, whereas the flow to the lower body is diminished. This
results in decreased pulses in the lower extremities, whereas bounding
pulses (3+ brachial pulses) in the upper extremities.
54- The nurse has taught a client with acne self-management
techniques. Which of the following statements by the client would
indicate a correct understanding of the teaching? Select all that
apply.
"I should wash my face daily with a mild cleanser."
"I should avoid using oil-based products on my skin."
"I should avoid sun-tanning booths and use sunscreen."
The nurse should instruct clients to wash their faces daily with a mild
cleanser to remove any build-up and debris. Oil-based products should be
avoided because they are comedogenic and may contribute to the
development of acne. It is recommended that tanning beds and prolonged
sunlight without appropriate SPF should be avoided because they may
cause scarring and are a risk factor for skin cancer.

55- The nurse is assessing a child with iron deficiency anemia.

Which of the following would be an expected finding? Select all that
apply.
Tachycardia
Pica
Pallor
Fatigue
Tachycardia is an expected assessment finding for a client with iron
deficiency anemia. When the client has decreased oxygen delivery to the
tissues, the body increases the heart rate to compensate. Pica is an
expected assessment finding for a client with iron deficiency anemia. Pica is
defined as “a tendency or craving to eat substances other than normal food
(such as clay, plaster, or ashes)” This is due to the low iron level in the
body. Pallor is an expected assessment finding for a client with iron
deficiency anemia. Due to low iron levels, there is decreased oxygen
delivery to the tissues and reduced perfusion. This causes pallor and other
signs of decreased perfusion. Fatigue is a non-specific finding in anemia
because of the decreased circulating hemoglobin that supplies oxygen to
organs and tissue.

56- The nurse is caring for a 4-year-old client who suffered second
and third-degree burns to the chest, abdomen, and legs. Vital signs:
P 117, RR 44, BP 90/60, pulse oximetry reading 88% on room air.
The nurse should initially
prepare the client for airway intubation.
The client is tachycardic, tachypneic, and has hypoxia. This client needs
intubation and mechanical ventilation to secure an airway and prevent
rapid respiratory failure due to inhalation injury.

57- You are monitoring an 18-month-old child who has just had
surgical correction of an epispadias completed. Which of the
following assessment findings would the nurse need to report to the
healthcare provider?
Cloudy, foul-smelling urine.
Stent in the meatus appears clogged.
Resting heart rate of 180 bpm
Cloudy, foul-smelling urine could indicate an infection and needs to be
reported to the healthcare provider. If the stent placed in the urethral
meatus appears clogged, no urine will be able to exit the bladder. This
needs to be corrected surgically, and the provider needs to be notified. A
heart rate of 180 bpm in an 18-month old child is considered tachycardia.
The child may be in pain or could be developing an infection, which needs
to be reported to the healthcare provider.

58- The nurse is discussing with a group of teenagers with cancer

the side effects associated with prescribed chemotherapy. Which
topic should the nurse consider prioritizing?
Alopecia
Teenagers are often egocentric, and their physical looks are important.
Most chemotherapy medications may cause an individual to develop
alopecia. This could have a significant negative impact on a client's self-
esteem. Chemotherapy has a broad spectrum of side effects. Still, hair loss
should be explicitly discussed for teenagers because it will most certainly
impact their appearance and make them more self-conscious. Allowing
teenage clients to express themselves and their potential anger is
essential. The nurse should convey empathy while remaining optimistic as
most hair will regrow, although with a different texture.

59- The nurse is assessing a client diagnosed with an

atrioventricular canal, the nurse is aware that many infants with
this condition also receive a diagnosis of which of the following?
Trisomy 21
Trisomy 21, or Down's Syndrome, is commonly associated with an
atrioventricular canal. Infants with trisomy 21 also commonly present with
an atrial septal defect (ASD) or ventricular septal defect (VSD).

60- The nurse is caring for a child with nephroblastoma. To prevent

complications from this tumor, the nurse should closely monitor the
client's
Blood pressure.
Nephroblastoma, also known as Wilms tumor, is a kidney tumor that
primarily affects children. Hypertension may occur because of the surge in
renin triggered by the tumor.

61- The nurse is assessing a child with newly onset congestive heart
failure. Which of the following assessment findings would be
expected? Select all that apply.
tachypnea
diaphoresis
fatigue
Tachypnea is an early sign of heart failure. The child's body works hard to
compensate for the decrease in cardiac output, so they breathe more
quickly to try to make up for the decreased oxygen delivery (Choice B).
Diaphoresis is a ubiquitous sign of heart failure, especially in the infant. The
child's body is fatigued as it works hard to compensate for the decreased
cardiac output (Choice E). Therefore they sweat profusely during exertion
and sometimes even at rest (Choice C).

62- The nurse is caring for a child with nephroblastoma. The nurse
plans to take which action?
Post a sign that states, “Do not palpate abdomen"
Nephroblastoma (Wilms tumor) is the most common childhood cancer.
Common treatments include surgical removal followed by chemotherapy.
Nursing care involves minimal manipulation of the abdomen (no palpation)
and a posted sign. It is essential to keep the encapsulated tumor intact.

63- The nurse is assessing vital signs for a client diagnosed with
acute lymphoblastic leukemia (ALL). The client's temperature is
101.6°F (38.7°C).
The nurse should prioritize
Initiating a peripheral vascular access device.
The client will need a vascular access device because the client will need to
have blood cultures obtained and possibly prescribed isotonic fluids and
antibiotics. The client with ALL is at risk for developing an infection, and the
client's fever is a concerning sign.

64- The nurse is creating a care plan for a child recovering from a
hematopoietic stem cell transplant. The nurse is most concerned
about the client's risk for
Infection.
Infection is a significant concern following stem cell transplant. Following
this procedure, bacterial, fungal, and viral infections present a significant
threat. Prescriptions for prophylactic antibiotics, such as azithromycin and
doxycycline, may be prescribed to cover the most common causes of
postprocedure bacterial infections.
65- The nurse cares for a 12-year-old client one-hour post-operative
following transsphenoidal hypophysectomy. After reviewing the
assessment findings, the nurse should take which action? Select all
that apply. See the exhibit.
notify the health care provider of the
urine output.
request an order for intravenous (IV)
fluids
document the findings
continue to monitor neurological status

This is an excessive amount of urine output for 1 hour and is concerning for
diabetes insipidus, given the procedure the client recently underwent. Any
urine output greater than 300 mL is alarming, and the healthcare provider
should be notified immediately. Diabetes insipidus is a severe complication
from neurosurgery that occurs around the pituitary. This amount of urinary
output can lead to shock if not treated promptly.

66- The nurse is performing a physical assessment on a four-month-

old-infant. The nurse is demonstrating an appropriate assessment
technique by
auscultating the left 4th intercostal space, midclavicularly for 60 seconds.

Auscultating the apical pulse for 60 seconds is the most accurate way
to assess the heart rate of a 4-month-old infant. The nurse should
auscultate instead of palpate because it is difficult to accurately count
the pulse rate via palpation on a moving 4-month-old. Due to
irregularities, a full minute should be auscultated to ensure the most
accurate heart rate is recorded. The apex is the best location for this
assessment, and in infants, it is located at the 4th intercostal space
(ICS) to the left of the sternum at the midclavicular line. In adults,
the apex is located at the 5th intercostal space (ICS) to the left of the
sternum at the midclavicular edge.

67- The nurse is assessing a child suspected of having hemophilia A.

Which of the following findings would support the diagnosis of
hemophilia A? Select all that apply.
prolonged activated partial thromboplastin time (aPTT)
hematuria
A prolonged activated partial thromboplastin time (aPTT) would be an
expected finding. Individuals with mild hemophilia may not have a
prolonged aPTT. However, this test is commonly used to narrow the
diagnosis to hemophilia A. The reason for using the aPTT is that this
laboratory test measures factor VIII.

68- The nurse is counseling parents concerned about their child

experiencing frequent nocturnal enuresis. The nurse should
recommend the parents to do which of the following?
Establish and maintain a voiding diary for the child.
Establishing a voiding diary/log for the client is an effective strategy.
Keeping a voiding diary helps identify patterns and triggers related to
nocturnal enuresis. It provides valuable information for healthcare providers
to tailor interventions to.
69- The nurse is caring for a client receiving digoxin. It would be
a priority for the nurse to monitor the client's
Potassium.
The nurse must monitor potassium levels while the client is taking digoxin.
Low levels of potassium may precipitate digoxin toxicity.

70- A nurse is assessing a pediatric patient with right-sided heart

failure. Which of the following assessment findings should the nurse
expect to observe? Select all that apply.
Ascites
Hepatosplenomegaly
Swellings of legs, ankles and feet
Ascites is indicative of right-sided heart failure. This would be due to the
right ventricle not pumping sufficient amounts of blood to the lungs;
therefore, the blood backs up in the body, causing an increased amount of
fluid in the interstitial space. Any signs or symptoms involving an increase
in fluid status indicate right-sided heart failure (Choice C).
Hepatosplenomegaly is indicative of right-sided heart failure. This would be
due to the right ventricle not pumping sufficient amounts of blood to the
lungs, and therefore blood backs up in the body, causing an increased
amount of fluid in the liver and spleen, which leads to their enlargement.
Any signs or symptoms involving increased fluid status would indicate right-
sided heart failure (Choice D). Peripheral edema is a common sign of right-
sided heart failure in pediatric patients (Choice E).

71- You are reinforcing counseling for two parents who are
preparing for the birth of their first child. The father has sickle cell
anemia, and the mother is a carrier. You tell them that their baby
has what chance of having sickle cell anemia?
50%
Sickle cell anemia is an autosomal recessive disease. The normal
chromosome is represented as S, and the sickle cell gene-containing
chromosome is expressed as s. Therefore, ss characterizes sickle cell
anemia, Ss defines the carrier, and SS is the normal phenotype. The baby
has a 50% chance of having sickle cell anemia (ss). From the information
presented in the question, the father is ss because he has the disease, and
the mother is Ss since she is a carrier. The disease is referred to as sickle
cell anemia or sickle cell disease, whereas the carrier state is referred to as
sickle cell trait.

Sickle cell anemia is inherited in an autosomal recessive pattern,

which means that both copies of the gene in each cell should have the
mutations necessary to have that disease (ss). The parents of an individual
with an autosomal recessive condition such as sickle cell
disease must each carry one copy of the mutated gene. The odds or
chances of the offspring having the disease or carrier state are determined
by the Punnett square. Based on the combinations, the baby has a 50%
chance of having sickle cell disease (ss).

The Punnett square in this case, is as follows:

72- Which of
the following patients would be considered most at risk for iron-
deficiency anemia?
A 13-month-old who will only drink cow’s milk and is very pale.

12 to 16-month-olds are at increased risk for iron deficiency anemia. At

this age, they no longer have maternal stores of iron left over, they are
picky eaters, and often do not consume enough iron in their diet. Cow’s
milk is not a good source of iron and we know children at this age who only
drink cow’s milk are at increased risk for iron-deficiency anemia. Also, the
question states that the child is very pale, so we suspect iron deficiency
anemia may be a problem.