Question 15

A client is admitted with infective endocarditis (IE). Which finding would alert the nurse
to a complication of this condition?
A) dyspnea
B) heart murmur
C) macular rash
D) hemorrhage
Review Information: The correct answer is B: heart murmur. Large, soft, rapidly
developing vegetations attach to the heart valves. They have a tendency to break off, causing
emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of
cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore,
the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain
and lungs, and obstruct blood flow.

Question 16
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The
nurse knows the client understands the procedure when the client says, "I will receive
tissue from
A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
Review Information: The correct answer is C: my thigh.". Autografts are done with tissue
transplanted from the client''s own skin.

Question 17
A client is admitted to the emergency room following an acute asthma attack. Which of
the following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills
Review Information: The correct answer is A: Diffuse expiratory wheezing. In asthma, the
airways are narrowed, creating difficulty getting air in. A wheezing sound results.

Question 18
A client has been admitted with a fractured femur and has been placed in skeletal
traction. Which of the following nursing interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed
Review Information: The correct answer is B: Frequent neurovascular assessments of the
affected leg. The most important activity for the nurse is to assess neurovascular status.
Compartment syndrome is a serious complication of fractures. Prompt recognition of this
neurovascular problem and early intervention may prevent permanent limb damage.

Question 19
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days
ago. The client has many questions about this condition. What area is a priority for the
nurse to discuss at this time?
A) Daily needs and concerns
B) The overview cardiac rehabilitation
C) Medication and diet guideline
D) Activity and rest guidelines
Review Information: The correct answer is A: Daily needs and concerns. At 2 days post-
MI, the client’s education should be focused on the immediate needs and concerns for the
day.

Question 20
A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching
his bottom and wetting the bed at night." Based on these complaints, the nurse would
initially assess for which problem?
A) allergies
B) scabies
C) regression
D) pinworms
Review Information: The correct answer is D: pinworms. Signs of pinworm infection
include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-
wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by
a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads
to intense itching in the area of its burrows.

Question 21
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing
diagnosis is a priority?
A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury
Review Information: The correct answer is B: Ineffective airway clearance. The most
common form of TEF is one in which the proximal esophageal segment terminates in a blind
pouch and the distal segment is connected to the trachea or primary bronchus by a short
fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing
aspiration. Other nursing diagnoses are then addressed.

Question 22
The nurse is developing a meal plan that would provide the maximum possible amount
of iron for a child with anemia. Which dinner menu would be best?
A) Fish sticks, french fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk
Review Information: The correct answer is B: Ground beef patty, lima beans, wheat roll,
raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables,
legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice: It is
high in iron and is appropriate for a toddler.

Question 23
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should
observe for signs of which overall imbalance?
 A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium
Review Information: The correct answer is B: Metabolic alkalosis. Vomiting causes loss of
acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to
metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes,
muscle twitching and elevated pulse. Options C and D are correct answers but not the best
answers since they are too general.

Question 24
A two year-old child is brought to the provider's office with a chief complaint of mild
diarrhea for two days. Nutritional counseling by the nurse should include which
statement?
A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water
Review Information: The correct answer is B: Continue with the regular diet and include
oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to
maintain a normal diet with fluids to rehydrate.

Question 25
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with
gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet
should include
A) formula or breast milk
B) broth and tea
C) rice cereal and apple juice
D) gelatin and ginger ale
Review Information: The correct answer is A: formula or breast milk. The usual diet for a
young infant should be followed.

Question 26
A child is injured on the school playground and appears to have a fractured leg. The first
action the school nurse should take is
A) call for emergency transport to the hospital
B) immobilize the limb and joints above and below the injury
C) assess the child and the extent of the injury
D) apply cold compresses to the injured area
Review Information: The correct answer is C: assess the child and the extent of the injury.
When applying the nursing process, assessment is the first step in providing care. The "5 Ps"
of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).

Question 27
The mother of a 3 month-old infant tells the nurse that she wants to change from formula
to whole milk and add cereal and meats to the diet. What should be emphasized as the
nurse teaches about infant nutrition?
A) Solid foods should be introduced at 3-4 months
B) Whole milk is difficult for a young infant to digest
 C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings
Review Information: The correct answer is B: Whole milk is difficult for a young infant to
digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd
is difficult to digest. In addition, it contains little iron and creates a high renal solute load.

Question 28
The nurse is preparing a handout on infant feeding to be distributed to families visiting the
clinic. Which notation should be included in the teaching materials?
A) Solid foods are introduced one at a time beginning with cereal
B) Finely ground meat should be started early to provide iron
C) Egg white is added early to increase protein intake
D) Solid foods should be mixed with formula in a bottle
Review Information: The correct answer is A: Solid foods are introduced one at a time beginning with cereal.
Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another
may be added in a week. Iron fortified cereal is the recommended first food.

Question 29
The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-
occlusive crisis of the elbow should include which one of the following as a priority?
A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise
Review Information: The correct answer is B: Client controlled analgesia. Management of
a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of
care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum
comfort.

Question 30
The nurse is performing a physical assessment on a toddler. Which of the following
actions should be the first?
A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail
Review Information: The correct answer is B: Use minimal physical contact. The nurse
should approach the toddler slowly and use minimal physical contact initially so as to gain
the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief
simple explanations just prior to the action.

Question 31
What finding signifies that children have attained the stage of concrete operations
(Piaget)?
A) Explores the environment with the use of sight and movement
B) Thinks in mental images or word pictures
C) Makes the moral judgment that "stealing is wrong"
D) Reasons that homework is time-consuming yet necessary
Review Information: The correct answer is C: Makes the moral judgment that "stealing is
wrong". The stage of concrete operations is depicted by logical thinking and moral
judgments.

Question 32
The mother of a child with a neural tube defect asks the nurse what she can do to
decrease the chances of having another baby with a neural tube defect. What is the best
response by the nurse?
A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."
Review Information: The correct answer is A: "Folic acid should be taken before and after
conception.". The American Academy of Pediatrics recommends that all childbearing
women increase folic acid from dietary sources and/or supplements. There is evidence that
increased amounts of folic acid prevents neural tube defects.

Question 33
The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day.
Which of these foods would the nurse reinforce for the client to eat at least daily?
A) Spaghetti
B) Watermelon
C) Chicken
D) Tomatoes
Review Information: The correct answer is B: Watermelon. Watermelon is high in
potassium and will replace potassium lost by the diuretic. The other foods are not high in
potassium.

Question 34
While teaching the family of a child who will take phenytoin (Dilantin) regularly for
seizure control, it is most important for the nurse to teach them about which of the
following actions?
A) Maintain good oral hygiene and dental care
B) Omit medication if the child is seizure free
C) Administer acetaminophen to promote sleep
D) Serve a diet that is high in iron
Review Information: The correct answer is A: Maintain good oral hygiene and dental care.
Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular
visits to the dentist should be emphasized.

Question 35
The nurse is offering safety instructions to a parent with a four month-old infant and a
four year-old child. Which statement by the parent indicates understanding of
appropriate precautions to take with the children?
A) "I strap the infant car seat on the front seat to face backwards."
"I place my infant in the middle of the living room floor on a blanket to play with
B)
my four year-old while I make supper in the kitchen."
"My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air
C)
while the four year-old naps on the sofa."
"I have the four year-old hold and help feed the four month-old a bottle in the
D)
kitchen while I make supper."
Review Information: The correct answer is D: "I have the four year-old hold and help feed
the four month-old a bottle in the kitchen while I make supper.". The infant seat is to be
placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are

Question 36
The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show
a femur fracture near the epiphysis. The parents ask what will be the outcome of this
injury. The appropriate response by the nurse should be which of these statements?
A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children."
Review Information: The correct answer is B: "In some instances the result is a retarded
bone growth.". An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded
bone growth. The leg often will be different in length than the uninjured leg.

Question 37
The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and
will be back at 6 PM.” A few hours later the child asks the nurse when the parents will
come again. What is the best response by the nurse?
A) "They will be back right after supper."
B) "In about 2 hours, you will see them."
C) "After you play awhile, they will be here."
D) "When the clock hands are on 6 and 12."
Review Information: The correct answer is A: "They will be back right after supper.". Time
is not completely understood by a 4 year-old. Preschoolers interpret time with their own
frame of reference. Thus, it is best to explain time in relationship to a known, common
event.

Question 38
The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse
would emphasize that pancreatic enzymes should be taken
A) once each day
B) 3 times daily after meals
C) with each meal or snack
D) each time carbohydrates are eaten
Review Information: The correct answer is C: with each meal or snack. Pancreatic enzymes
should be taken with each meal and every snack to allow for digestion of all foods that are
eaten.

Question 39
A nurse is providing a parenting class to individuals living in a community of older
homes. In discussing formula preparation, which of the following is most important to
prevent lead poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
Review Information: The correct answer is C: Let tap water run for 2 minutes before
adding to concentrate. Use of lead-contaminated water to prepare formula is a major source
of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or
lead solder used in sealing water pipes. Letting tap water run for several minutes will
diminish the lead contamination.

Question 40
Which of the following manifestations observed by the school nurse confirms the
presence of pediculosis capitis in students?
A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
Review Information: The correct answer is D: Whitish oval specks sticking to the hair.
Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly
attached to the hair shafts. Treatment can include application of a medicated shampoo with
lindane for children over 2 years of age, and meticulous combing and removal of all nits.

Question 41
When interviewing the parents of a child with asthma, it is most important to assess the
child's environment for what factor?
A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus
Review Information: The correct answer is A: Household pets. Animal dander is a very
common allergen affecting persons with asthma. Other triggers may include pollens,
carpeting and household dust.

Question 42
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV,
Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries
inconsolably for as long as 3 hours, and has had several shaking spells. In addition to
referring her to the emergency room, the nurse should document the reaction on the
baby's record and expect which immunization to be most associated with the findings the
infant is displaying?
A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza
Review Information: The correct answer is A: DTaP. The majority of reactions occur with
the administration of the DTaP vaccination. Contradictions to giving repeat DTaP
immunizations include the occurrence of severe side effects after a previous dose as well as
signs of encephalopathy within 7 days of the immunization.

Question 43
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's
screaming every time the mother gets ready to leave the hospital room. What is the best
response by the nurse?
A) "I think you or your partner needs to stay with the child while in the hospital."
B) "Oh, that behavior will stop in a few days."
C) "Keep in mind that for the age this is a normal response to being in the hospital."
D) "You might want to "sneak out" of the room once the child falls asleep."
Review Information: The correct answer is C: "Keep in mind that for the age this is a
normal response to being in the hospital.". The protest phase of separation anxiety is a
normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak