GI & Nutrition
A nurse is teaching parents about foods for a child with celiac disease. Which foods should be avoided?
Barley, Rye, Wheat
Rationale: Gluten-containing grains (wheat, barley, rye) must be avoided; rice and corn are safe.
A child arrives with headache and dizziness after spending time in a poorly ventilated home. Pulse oximetry reads 99%. What is the nurse’s priority action?
Give 100% oxygen, initiate non-rebreather with 100%, or initiate HFNC with 100%
Rationale: The key is giving 100% oxygen. Immediate administration of 100% oxygen is the priority intervention.
A nurse is preparing to administer an intramuscular medication to an infant. Which injection site is the safest and most appropriate?
Vastus lateralis
Rationale: The vastus lateralis is well-developed in infants and free of major nerves and vessels, making itthe safest site.
Which Erikson psychosocial stage is most characteristic of school-aged children?
Industry vs. Inferiority
Rationale:
School-aged children focus on developing competence and pride in their abilities through schooland social activities, which aligns with Erikson’s stage of industry versus inferiority
Which safety intervention best prevents accidental poisoning in toddlers?
Lock medications out of reach
Rationale: Locked storage prevents toddler access; childproof caps alone may fail, and teaching children alone is insufficient
A child is being discharged home on total parenteral nutrition (TPN) through a central venous catheter. What is the MOST important teaching priority for the family? (Hint: Think about the central line)
Signs and symptoms of central line infection
Rationale: TPN is administered through a central line, and the most serious home complication is infection, which can quickly lead to sepsis. Families must be able to recognize early warning signs such as fever, redness, swelling, or drainage at the site.
Name at least 2 signs that indicate early hypoxia in a child with respiratory distress.
Tachycardia, Tachypnea / increased work of breathing, Anxiety or irritability, Nasal flaring, feeding / poor feeding, restlessness, or agitation
Rationale: These are all early sign of hypoxia; bradycardia, cyanosis, and hypotension are late signs.
A nurse is calculating daily maintenance fluids for a pediatric patient who weighs 40 kg. Using the standard pediatric maintenance fluid formula, what is the child’s 24-hour fluid requirement?
1,900 mL per day
Rationale: Daily pediatric maintenance fluids are calculated using the Holliday–Segar method:
First 10 kg × 100 mL/kg = 1,000 mL Second 10 kg × 50 mL/kg = 500 mL Remaining 20 kg × 20 mL/kg = 400 mL
Total: 1,000 + 500 + 400 = 1,900 mL in 24 hours
A post-tonsillectomy child is observed swallowing frequently. What is the priority nursing action?
Suspect postoperative bleeding, assess for postoperative hemorrhage and notify the surgeon
Rationale: Frequent swallowing may indicate bleeding, a potentially life-threatening complication, requiring immediate assessment and intervention.
A 3-year-old hospitalized for a broken arm becomes clingy and refuses to let the parent leave. What is the best nursing action?
Allow the child to remain close to the parent and approach slowly
Other answer choices: minimize separation, provide atraumatic nursing care
Rationale: Toddlers experience separation anxiety and feel safer when a parent is present; approaching slowly while the parent is near helps reduce fear.
Which stool characteristic is most consistent with biliary atresia?
Pale, clay-colored stools
Rationale: Biliary atresia causes impaired bile flow, resulting in pale or clay-colored stools.
Which laboratory test confirms a diagnosis of cystic fibrosis?
A sweat chloride test (>60mmol/L)
Rationale: A sweat chloride level greater than 60 mmol/L is the diagnostic standard for cystic fibrosis because CFTR dysfunction causes abnormally high chloride in swea
What drug is used for routine and rapid “rescue” relief for acute asthma exacerbations?
Albuterol (SABA), Short-acting bronchodilator
Rationale: Short-acting bronchodilators and Albuterol provide rapid relief; other medications are for maintenance therapy.
A hospitalized toddler refuses to share toys with a sibling visiting. What developmental behavior does this represent? (Egocentrism, Regression, or Sibling Rivalry?)
The child is exhibiting normal egocentrism
Rationale: Toddlers commonly refuse to share because egocentrism is a normal developmental trait at this age—they are naturally self-focused and possessive of toys. This behavior is not best explained by regression, which involves returning to earlier behaviors (such as thumb-sucking or bedwetting) in response to stress, nor is it primarily sibling rivalry, which refers to jealousy or competition between siblings rather than typical toddler sharing difficulty
A nurse is providing safety education to the parents of a 2-year-old toddler. Which safety concern is highest priority for this age group? (Hint: Think about how toddlers explore their environment)
Poisoning
Rationale: Toddlers explore their environment by putting objects into their mouths and lack the ability to recognize danger. This makes accidental poisoning from medications, cleaning products, and other household substances the highest safety concern for this age group.
An infant has forceful vomiting after feeds and remains hungry afterward. Which physical assessment finding best supports pyloric stenosis?
Palpable upper abdominal mass, Olive shaped mass in RUQ, or abdominal distension
Rationale: Pyloric stenosis causes projectile, non-bilious vomiting and may present with a palpable “olive-like” mass in the upper abdomen.
A nurse is assessing a 2-year-old with worsening respiratory distress. Name at least 2 concerning signs of impending respiratory failure?
Severe/worsening tachypnea, bradypnea, altered mental status, continued hypoxia with supplemental O2, worsening retractions/WOB, worsening restlessness/irritability
Rationale: These signs indicate significant respiratory compromise and requires prompt intervention.
A child with a fever of 103°F receives acetaminophen (Tylenol) but vomits 15 minutes later and remains tachycardic. What is the nurse’s priority action?
Do NOT automatically re-dose; assess the child and notify the provider for guidance while initiating fever-reduction measures.
Rationale:Because acetaminophen may have been partially absorbed, re-dosing too soon risks overdose. The nurse should focus on assessment, supportive cooling measures, and provider direction before repeating the dose
A school-age child has sudden painless rectal bleeding but no fever, vomiting, or diarrhea. What condition should the nurse suspect?
Meckel diverticulum
Rationale: Meckel diverticulum commonly presents with painless bright red rectal bleeding due to ectopic gastric tissue. It is a congenital GI abnormality often requiring surgical management.
Physical punishment such as spanking is most likely to lead to which outcome in children? (Moral reasoning, Misbehaving, or Decreased aggressing in the future?)
Misbehaving
Rationale: Physical punishment such as spanking may stop behavior temporarily, but it does not help children develop internal moral reasoning or long-term self-discipline. Instead, it often teaches obedience based on fear, and children may be more likely to misbehave when caregivers are not present. Spanking is also not associated with decreased aggression and can contribute to negative behavioral outcomes over time.
A pediatric nurse is assessing a toddler who consumes large amounts of cow’s milk daily and eats very few solid foods. The nurse recognizes that this dietary pattern places the child at greatest risk for a deficiency of which vitamin?
Iron deficiency
Rationale: Drinking too much cow’s milk can lead to iron deficiency because milk is low in iron and can replace iron-rich foods in a child’s diet. This makes iron deficiency common in children who consume a high-milk diet.
In an infant, what finding indicates respiratory arrest and requires immediate intervention?
Apnea, Cessation of breathing, HR <60 with signs of poor perfusion (required CPR)
Rationale: Apnea indicates respiratory arrest and requires immediate intervention. In infants, hypoxia quickly leads to bradycardia; therefore, a heart rate < 60 bpm with signs of poor perfusion signals severe oxygen deprivation and requires immediate CPR to prevent cardiac arrest.
A child with prolonged vomiting is prescribed IV fluids. Before potassium is added, the nurse must confirm which key clinical assessment finding?
UOP > 1mL/kg/hr, adequate urine output present
Rationale: Potassium should never be administered unless renal function is confirmed through adequate urine output, because impaired excretion increases the risk of life-threatening hyperkalemia.
A hospitalized toddler cries when the nurse enters the room. What should the nurse do first?
Approach slowly and allow the child to stay close to the parent
Other answer options: encourage the parent/caregiver to remain with the child; Use a calm, gentle voice and avoid sudden movements; Offer a favorite toy or comfort object (transitional object); Get down to the child’s eye level and use age-appropriate communication
Rationale: Toddlers experience stranger anxiety; allowing proximity to a parent while approaching slowly provides comfort and reduces stress.
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According to anticipatory guidance based on developmental stage, which safety concern poses the greatest risk for adolescents? (Hint: Think mechanism of injury)
Motor vehicle–related injuries
Rationale:
Adolescents are at highest risk for motor vehicle injuries due to risk-taking behaviors, peer influence, and limited driving experience.