Tiny Humans, Big Problems
3. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a newborn with Apgar scores of 1 and 4, born at 41 weeks’ gestation. In planning for admission of this newborn, what is the nurse’s highest priority?
1 Turn on the apnea and cardiorespiratory monitors.
2 Connect the resuscitation bag to the oxygen outlet.
3 Set up the intravenous line with 5% dextrose in water.
4 Set the radiant warmer control temperature at 36.5° C (97.6° F)
2 Connect the resuscitation bag to the oxygen outlet.
4. The nurse is giving report to an assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity?
1 Every 2 hours
2 Every 3 hours
3 Every 4 hours
4 Every 6 hours
1. Every 2 hours
2. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse would place the infant in which best position at this time?
1 Prone position
2 On the stomach
3 Left lateral position
4 Right lateral position
3. Left lateral position
2. The parent of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The parent tells the nurse that the child complains of discomfort on the right side and that ibuprofen is ineffective. Which instruction would the nurse provide to the parent?
1 Increase the dose of ibuprofen.
2 Increase the frequency of ibuprofen.
3 Encourage the child to lie on the left side.
4 Encourage the child to lie on the right side.
4. Encourage the child to lie on the right side.
1. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider’s prescription?
1 Endotracheal intubation
2 100 units of NPH insulin
3 Intravenous infusion of normal saline
4 Intravenous infusion of sodium bicarbonate
3. Intravenous infusion of normal saline
4. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate ?
1 Apply gentle pressure.
2 Reinforce the dressing.
3 Document the findings.
4 Contact the primary health care provider (PHCP)
3 Document the findings.
5. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?
1 Wearing gloves when emptying the client’s bedpan
2 Keeping all linens in the room until the implant is removed
3 Wearing a lead apron when providing direct care to the client
4 Placing the client in a semiprivate room at the end of the hallway
4 Placing the client in a semiprivate room at the end of the hallway
5. A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which problem?
1 Diarrhea
2 Metabolic acidosis
3 Metabolic alkalosis
4 Hyperactive bowel sounds
3. Metabolic alkalosis
4. The clinic nurse is providing instructions to the parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the parent?
1 “The immunization schedule will need to be altered.”
2 “The child should not receive any hepatitis vaccines.”
3 “The child will receive all of the immunizations except for the polio series.” Page 464
4 “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.”
4. “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.”
3. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.
1.Increase in pH
2.Comatose state
3.Deep, rapid breathing
4.Decreased urine output
5.Elevated blood glucose level
2.Comatose state
3.Deep, rapid breathing
5.Elevated blood glucose level
5. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? Select all that apply.
1. Cyanosis
2. Tachypnea
3. Hypotension
4. Retractions
5. Audible grunts
6. Presence of a barrel chest
1. Cyanosis
2. Tachypnea
4. Retractions
5. Audible grunts
8. A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action?
1 Induce vomiting.
2 Call an ambulance.
3 Call the Poison Control Center.
4 Bring the child to the emergency department.
3 Call the Poison Control Center.
7. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child’s symptoms?
1 Watery diarrhea
2 Projectile vomiting
3 Increased urine output
4 Vomiting large amounts of bile
2. Projectile vomiting
5. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse would monitor for which indication that the child may be experiencing airway obstruction?
1 The child exhibits nasal flaring and bradycardia.
2 The child is leaning forward, with the chin thrust out.
3 The child has a low-grade fever and complains of a sore throat.
4 The child is leaning backward, supporting self with the hands and arms.
2. The child is leaning forward, with the chin thrust out.
7. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication?
1 An ampule of 50% dextrose
2 NPH insulin subcutaneously
3 IV fluids containing dextrose
4 Phenytoin for the prevention of seizures
3. IV fluids containing dextrose
6. The postpartum nurse is providing instructions to the parent of a newborn with hyperbilirubinemia who is being breast/chest-fed. The nurse would provide which instruction to the parent?
1 Feed the newborn less frequently.
2 Continue to breast/chest-feed every 2 to 4 hours.
3 Switch to bottle-feeding the infant for 2 weeks.
4 Stop breast/chest-feeding and switch to bottle-feeding permanently
2 Continue to breast/chest-feed every 2 to 4 hours.
10. The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?
1 Private room or cohort client
2 Personal respiratory protection device
3 Private room with negative airflow pressure
4 Mask worn by staff when the client needs to leave the room
1 Private room or cohort client
8. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse would teach the parents to include which food item in the child’s diet?
1 Rice
2 Oatmeal
3 Rye toast
4 Wheat bread
1. Rice
6. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The parent becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action?
1 Tell the parent that the child must stay in the tent.
2 Place a toy in the tent to make the child feel more comfortable.
3 Call the pediatrician and obtain a prescription for a mild sedative.
4 Let the parent hold the child and direct the cool mist over the child’s face.
4. Let the parent hold the child and direct the cool mist over the child’s face.
9. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?
1 Lack of knowledge
2 Inadequate fluid volume
3 Compromised family coping
4 Inadequate consumption of nutrients
2. Inadequate fluid volume
7. The nurse is assessing a newborn who was born to a birthing parent who is addicted to drugs. Which findings would the nurse expect to note during the assessment of this newborn? Select all that apply.
1. Lethargy
2. Sleepiness
3. Irritability
4. Constant crying
5. Difficult to comfort
6. Cuddles when being held
3. Irritability
4. Constant crying
5. Difficult to comfort
11. The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next ?
1 Check the client’s temperature.
2 Isolate the client in a private room.
3 Check a complete set of vital signs.
4 Contact the primary health care provider.
2. Isolate the client in a private room.
10. Which interventions would the nurse include when creating a care plan for a child with hepatitis? Select all that apply.
1.Providing a low-fat, well-balanced diet
2.Teaching the child effective handwashing techniques
3.Scheduling playtime in the playroom with other children
4.Notifying the primary health care provider (PHCP) if jaundice is present
5.Instructing the parents to avoid administering medications unless prescribed
6.Arranging for indefinite homeschooling because the child will not be able to return to school
1.Providing a low-fat, well-balanced diet
2.Teaching the child effective handwashing techniques
5.Instructing the parents to avoid administering medications unless prescribed
10. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply.
1.Place the infant in a private room.
2.Ensure that the infant’s head is in a flexed position.
3.Wear a mask, gown, and gloves when in contact with the infant.
4.Place the infant in a tent that delivers warm humidified air.
5.Position the infant on the side, with the head lower than the chest.
6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
1.Place the infant in a private room.
3.Wear a mask, gown, and gloves when in contact with the infant.
6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
12. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions would the nurse anticipate receiving? Select all that apply.
1.Initiate an infusion of 3% NaCl.
2.Administer intravenous furosemide.
3.Restrict fluids to 800 mL over 24 hours.
4.Elevate the head of the bed to high-Fowler’s.
5.Administer a vasopressin antagonist as prescribed.
1.Initiate an infusion of 3% NaCl.
3.Restrict fluids to 800 mL over 24 hours.
5.Administer a vasopressin antagonist as prescribed.