1. The student nurse is assigned to take the vital signs of the clients in the pediatric ward.

The
student nurse reports to the staff nurse that the parent of a toddler who is 2 days postoperative
after a cleft palate repair has given the toddler a pacifier. What would be the best immediate
action of the nurse?
A. Notify the pediatrician of this finding
B. Reassure the student that this is an acceptable action on the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the pacifier from the toddler’s mouth
RATIONALE: Nothing must be placed in the mouth of a toddler who just undergone a cleft palate
repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of
the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the
mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing
should enter the mouth until the suture line has completely healed.

2. The nurse is providing a health teaching to the mother of an 8-year-old child with cystic fibrosis.
Which of the following statement if made by the mother would indicate to the nurse the need for
further teaching about the medication regimen of the child?
A. “My child might need an extra capsule if the meal is high in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a cup of hot
RATIONALE: The pancreatic capsules contain pancreatic enzyme that should be administered in a
cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the
medication’s integrity.

3. The mother brought her child to the clinic for follow-up check up.  The mother tells the nurse that
14 days after starting an oral iron supplement, her child's stools are black.  Which of the following
is the best nursing response to the mother?
A. “I will notify the physician, who will probably decrease the dosage slightly”
B. “This is a normal side effect and means the medication is working”
C. “You sound quite concerned. Would you like to talk about this further?”
D. “I will need a specimen to check the stool for possible bleeding”
Feedback
When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents
of children receiving this medication should be advised that this side effect indicates the medication is
being absorbed and is working well.

4. An 8-year-old boy with asthma is brought to the clinic for check up.  The mother asks the nurse if
the treatment given to her son is effective. What would be the appropriate response of the nurse?
A. I will review first the child’s height on a growth chart to know if the treatment is working
B. I will review first the child’s weight on a growth chart to know if the treatment is working
C. I will review first the number of prescriptions refills the child has required over the last 6
months to give you an accurate answer
D. I will review first the number of times the child has seen the pediatrician during the last 6
months to give you an accurate answer
Feedback
Reviewing the number of prescription refills the child has required over the last 6 months would be
the best indicator of how well controlled and thus how effective the child’s asthma treatment is.
Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the
child take additional medication. This would be reflected in the number of prescription refills.

5. The nurse is caring to a child client who is receiving tetracycline.  The nurse is aware that in taking
this medication, it is very important to:
A. Administer the drug between meals
B. Monitor the child’s hearing
C. Give the drug through a straw
 D. Keep the child out of the sunlight
Feedback
Tetracycline may cause a phototoxic reaction.

6. A 14 day-old infant with a cyanotic heart defects and mild congestive heart failure is brought to the
emergency department.  During assessment, the nurse checks the apical pulse rate of the infant. 
The apical pulse rate is 130 beats per minute.  Which of the following is the appropriate nursing
action?
A. Retake the apical pulse in 15 minutes
B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled
Feedback
The normal heart rate of an infant is 120-160 beats per minute.

7. The physician prescribed gentamicin (Garamycin) to a child who is also receiving chemotherapy. 
Before administering the drug, the nurse should check the results of the child’s:
A. CBC and platelet count
B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays
Feedback
Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure;
thus baseline renal function must be evaluated before initiating either medication.

8. Which of the following is the suited size of the needle would the nurse select to administer the IM
injection to a preschool child?
A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch
Feedback
In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always
look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this
case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and
length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long
would be most appropriate.

9. A 9-year-old boy is admitted to the hospital.  The boy is being treated with salicylates for the
migratory polyarthritis accompanying the diagnosis of rheumatic fever.  Which of the following
activities performed by the child would give a best sign that the medication is effective?
A. Listening to story of his mother
B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player
Feedback
The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis
accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints
and would provide the nurse with a means of evaluating the child’s level of pain.

10. The physician decided to schedule the 4-year-old client for repair of left undescended testicle. 
The Injection of a hormone, HCG finds it less successful for treatment.  To administer a
pentobarbital sodium (Nembutal) suppository preoperatively to this client, in which position should
the nurse place him?
A. Supine with foot of bed elevated
B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg flexed
Feedback
The recommended position to administer rectal medications to children is side-lying with the upper
leg flexed. This position allows the nurse to safely and effectively administer the medication while
promoting comfort for the child.

11. The nurse is caring to a 24-month-old child diagnosed with congenital heart defect.  The physician
prescribed digoxin (Lanoxin) to the client.  Before the administration of the drug, the nurse checks
the apical pulse rate to be 110 beats per minute and regular.  What would be the next nursing
action?
A. Check the other vital signs and level of consciousness
B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
D. Check the apical and radial simultaneously, and if they are the same, give the digoxin.
Feedback
For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A
toddler’s normal pulse rate is slightly lower than an infant’s (120).

12. An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest
physiotherapy treatment.  The therapy should be properly coordinated by the nurse with the
respiratory therapy department so that treatments occur during:
A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule
Feedback
Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach
contents, because the child is placed in a variety of positions during the treatment process.

13. The nurse is providing health teaching about the breastfeeding and family planning to the client
who gave birth to a healthy baby girl.  Which of the following statement would alert the nurse that
the client needs further teaching?
A. “I understand that the hormones for breastfeeding may affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed less after birth”
C. “I may not have periods while I am breastfeeding, so I don’t need family planning”
D. “I can get pregnant as early as one month after my baby was born”
Feedback
It is common misconception that breastfeeding may prevent pregnancy.

14. A toddler is brought to the hospital because of severe diarrhea and vomiting.  The nurse assigned
to the client enters the client’s room and finds out that the client is using a soiled blanket brought
in from home.  The nurse attempts to remove the blanket and replace it with a new and clean
blanket.  The toddler refuses to give the soiled blanket.  The nurse realizes that the best
explanation for the toddler’s behavior is:
A. The toddler did not bond well with the maternal figure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions
Feedback
The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort
and safety when the maternal figure is not present or when in a new situation for which the toddler
was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket
for the toddler.

15. The nurse has knowledge about the developmental task of the child.  In caring a 3-year-old-client,
the nurse knows that the suited developmental task of this child is to:
A. Learn to play with other children
B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment
Feedback
Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order
to accomplish this, the toddler must be able to explore and manipulate the environment.

16. A mother who gave birth to her second daughter is so concerned about her 2-year old daughter. 
She tells the nurse, “I am afraid that my 2-year-old daughter may not accept her newly born
sister”.  It is appropriate to the nurse to response that:
A. The older daughter be given more responsibility and assure her “that she is a big girl now, and
doesn’t need Mommy as much”
B. The older daughter not have interaction with the baby at the hospital, because she may harm
her new sibling
C. The older daughter stay with her grandmother for a few days until the parents and new baby
are settled at home
D. The mother spend time alone with her older daughter when the baby is sleeping
Feedback
The introduction of a baby into a family with one or more children challenges parent to promote
acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the
stage for the other children’s reaction. Spending time with the older siblings alone will also reassure
them of their place in the family, even though the older children will have to eventually assume new
positions within the family hierarchy.

17. A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. 
Which of the following is an appropriate toy would the nurse select for the child:
A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
Feedback
The autonomous toddler would be frustrated by being confined to be. The pounding board and
hammer is developmentally appropriate and an excellent way for the toddler to release frustration.

18. Which of the following clients is at high risk for developmental problem?
A. A toddler with acute Glomerulonephritis on antihypertensive and antibiotics
B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic fibrosis
Feedback
It is the developmental task of an 18-month-old toddler to explore and learn about the environment.
The respiratory complications associated with cystic fibrosis (which are present in almost all children
with cystic fibrosis) could prevent this development task from occurring.

19. Which of the following would be the best divesionary activity for the nurse to select for a 2 weeks
hospitalized 3-year-old girl?
A. Crayons and coloring books
B. Doll
C. Xylophone toy
D. Puzzles
Feedback
The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or
makes a mess; xylophone which certainly makes noise or music would be the best choice.

20. A nurse is providing safety instructions to the parents of the 11-month-old child.  Which of the
following will the nurse includes in the instructions?
A. Plugging all electrical outlets in the house
B. Installing a gate at the top and bottom of any stairs in the home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the mouth
Feedback
An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the
installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.

21. An 8-year-old girl is in second grade and the parents decided to enroll her to a new school.  While
the child is focusing on adjusting to new environment and peers, her grades suffer.  The child’s
father severely punishes the child and forces her daughter to study after school.  The father does
not allow also her daughter to play with other children.  These data indicate to the nurse that this
child is deprived of forming which normal phase of development?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers
Feedback
In second grade a child needs to form a close relationships with peers.

22. A 5-year-old boy client is scheduled for hernia surgery.  The nurse is preparing to do preoperative
teaching with the child.  The nurse should knows that the 5-year-old would:
A. Expect a simple yet logical explanation regarding the surgery
B. Asks many questions regarding the condition and the procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery
Feedback
A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many
questions and in a situation such as this, could be expected to ask even more.

23. The nine-year-old client is admitted in the hospital for almost 1 week and is on bed rest.  The child
complains of being bored and it seems tiresome to stay on bed and doing nothing.  What activity
selected by the nurse would the child most likely find stimulating?
A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming staff development meeting
D. Listening to a compact disc
Feedback
A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys
“showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity
also provides the school-age child a needed opportunity to interact with others in the absence of
school and personal friends.

24. The parent of a 16-year-old boy tells the nurse that his son is driving a motorbike very fast and
with one hand.  “It is making me crazy!”  What would be the best explanation of the nurse to the
behavior of the boy?
A. The adolescent might have an unconscious death wish
B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how dangerous the behavior is
D. The adolescent has found a way to act out hostility toward the parent
Feedback
Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.
25. An 8-month-old infant is admitted to the hospital due to diarrhea.  The nurse caring for the client
tells the mother to stay beside the infant while making assessment.  Which of the following
developmental milestones the infant has reached?
A. Has a three-word vocabulary
B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers
Feedback
An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is
known as “stranger anxiety”.

26. The community nurse is conducting a health teaching in the group of married women.  When
teaching a woman about fertility awareness, the nurse should emphasize that the basal body
temperature:
A. Should be recorded each morning before any activity
B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a digital one
D. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test
Feedback
The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken
immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3
degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight
drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with
the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius.
This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

27. The community nurse is providing an instruction to the clients in the health center about the use of
diaphragm for family planning.  To evaluate the understanding of the woman, the nurse asks her
to demonstrate the use of the diaphragm.  Which of following statement indicates a need for
further health teaching?
A. “I should check the diaphragm carefully for holes every time I use it.”
B. “The diaphragm must be left in place for at least 6 hours after intercourse.”
C. “I really need to use the diaphragm and jelly most during the middle of my menstrual
cycle
D. “I may need a different size diaphragm if I gain or lose more than 20 pounds”
Feedback
The woman must understand that, although the “fertile” period is approximately midcycle, hormonal
variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be
inserted before every intercourse.

28. The client visits the clinic for prenatal check-up.  While waiting for the physician, the nurse decided
to conduct health teaching to the client.  The nurse informed the client that primigravida mother
should go to the hospital when which patter is evident?
A. Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual
cramps
C. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity
Feedback
Although instructions vary among birth centers, primigravidas should seek care when regular
contractions are felt about 5 minutes apart, becoming longer and stronger.

29. A nurse is planning a home visit program to a new mother who is 2 weeks postpartum and
breastfeeding, the nurse includes in her health teaching about the resumption of fertility,
contraception and sexual activity.  Which of the following statement indicates that the mother has
understood the teaching?
A. “Because breastfeeding speeds the healing process after birth, I can have sex right away and
not worry about infection”
 B. “Because I am breastfeeding and my hormones are decreased, I may need to use a
vaginal lubricant when I have sex”
C. “After birth, you have to have a period before you can get pregnant again’
D. “Breastfeeding protects me from pregnancy because it keeps my hormones down, so I don’t
need any contraception until I stop breastfeeding”
Feedback
Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.

30. The nurse assigned in the health center is counseling a 30-year-old client requesting oral
contraceptives.  The client tells the nurse that she has an active yeast infection that has recurred
several times in the past year.  Which statement by the nurse is inaccurate concerning health
promotion actions to prevent recurring yeast infection?
A. “During treatment for yeast, avoid vaginal intercourse for one week”
B. “Wear loose-fitting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water solution”
Feedback
Frequent douching interferes with the natural protective barriers in the vagina that resist yeast
infection and should be avoided.