Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus? A. Obtaining skull X-ray B. Measuring head circumference C. Performing a lumbar puncture D. Magnetic resonance imaging (MRI) Correct Answer: B. Measuring head circumference Measuring head circumference is the most… Read More »
You are the pediatric unit charge nurse today and is working with a new RN. Which action by the new RN requires the most immediate action on your part? A. The new RN wears goggles to change linens of a client who has diarrhea caused by C. difficile. B. The new RN places a child… Read More »
After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching? A. “We’ll follow these instructions until our child has completely grown and developed.” B. “Well follow these instructions until our child’s symptoms disappear.” C. “Our child must maintain these… Read More »
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching? A. Apply hydrocortisone cream under the cast using sterile applicator B. Apply cool air under the cast with a blow-dryer C. Use sterile applicators to scratch the… Read More »
A client comes to the outpatient clinic where you work complaining of abdominal pain, diarrhea, shortness of breath, and epistaxis. Which of the following actions would you take first? A. Screening clients for upper respiratory tract symptoms B. Call an ambulance to take the client immediately to the hospital C. Ask the client… Read More »
A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expect to find? A. Open anterior and fontanel and closed posterior fontanel B. Closed anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D.… Read More »
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first? A. Assess vital signs B. Institute seizure precautions C. Assess neurologic status D. Place in respiratory isolation Correct Answer: D. Place in… Read More »
A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? A. Obtain blood, urine, and sputum for cultures B. Infuse normal saline at 100ml/hr… Read More »
Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause: A. Dehydration B. Hypovolemic shock C. Cerebral edema D. Heart failure Correct Answer: C. Cerebral edema Due to the inflammation of… Read More »
A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A. Reverse isolation B. Respiratory isolation C. Contact isolation D. Standard precautions Correct Answer: C. Contact isolation Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g.… Read More »