1. 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.
b.Right foot is cool to the touch and appears pale and blanched.
2. 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. Duckthatsqueaks.
B. Fashiondollandclothes.
C. Set of cloth and hand puppets.
D. Hand held video game.
C. Set of cloth and hand puppets.
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3. 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.
C. Place the infant in a knee-chest position.
, 4. 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. Metabolicalkalosis.
B. Respiratory acidosis.
C. Respiratoryalkalosis.
D. Metabolic acidosis.
D. Metabolic acidosis.
5. 7 years 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.
C. Serum potassium of 3.0 mg/dL.
6. The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease).
Choosing which food indicates that the teaching has been effective?
A. Creamed corn.
B. Pancakes.
C. Rye crackers.
D. Cooked oatmeal.
A. Creamed corn.
7. 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. Associativeplay.
C. Object prehension.
D. Object permanence.
D. Object permanence.
8. 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. Measuretheinfant'shead-to-toelength.
B. Palpate the anterior fontanel for tension and bulging.
C. Observe the infant for sunken eyes.
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