The nurse is caring for a 3-year-old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? A. Blood pressure trend is downward, and pulse is rapid and irregular. B. Right foot is cool to the touch and appears pale and blanched. C. Pulse distal to the femoral artery is weaker on the left foot than right foot. D. The pressure dressing at right femoral area is moist and oozing blood. Ans. B
Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse for this 3-year-old child? A. Duck the squeaks. B. Fashion doll and clothes. C. Set of cloth and hand puppets. D. Handheld video game. Ans. C
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? A. Administer morphine sulphate. B. Start IV fluids. C. Place the infant in a knee-chest position. D. Provide 100% oxygen by face mask. Ans. C
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? A. Metabolic alkalosis. B. Respiratory acidosis. C. Respiratory alkalosis. D. Metabolic acidosis Ans. D
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? A. Gastric output of 100 mL in the last 8 hours. B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips. C. Serum potassium of 3.0 mg/dL. D. Serum pH of 7.45. Ans. C
The nurse is evaluating diet teaching for a client who has non tropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective? A. Creamed corn. B. Pancakes. C. Rye crackers. D. Cooked oatmeal. Ans. A
During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? A. Separation anxiety. B. Associate play. C. Object prehension. D. Object permanence. Ans. D
The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? A. Measure the infant’s head-to-toe length. B. Palpate the anterior fontanel for tension and bulging. C. Observe the infant for sunken eyes.