A nurse is caring for a school-age child who has experienced
a tonic-clonic seizure. Which of the following actions should
the nurse take during the immediate postictal period? -
...ANSWER...Place the child in a side-lying position.
Rationale: The nurse should place the child in a side-lying
position to prevent aspiration.
A nurse is teaching the parent of a preschooler about ways to
prevent acute asthma attacks. Which of the following
statements by the parent indicates an understanding of the
teaching? - ...ANSWER..."I should keep my child indoors
when I mow the yard."
Rationale: The nurse should instruct the parent to keep the
preschooler indoors during lawn maintenance or when the
pollen count is increased. Guarding against exposure to
known allergens found outdoors, such as grass, tree, and weed
pollen, will decrease the frequency of the preschooler's
asthma attacks.
A nurse is caring for a preschooler whose father is going
home for a few hours while another relative stays with the
child. Which of the following statements should the nurse
make to explain to the child when their father will return? -
...ANSWER..."Your daddy will be back after you eat."
Rationale: Preschoolers make sense of time best when they
can associate it with an expected daily routine, such as meals
and bedtime. Therefore, the child comprehends time best
when it is explained to them in relation to an event they are
familiar with, such as eating.
A nurse is admitting a school-age child who has Pertussis.
Which of the following actions should the nurse take? -
...ANSWER...Initiate droplet precautions for the child.
Rationale: The nurse should initiate droplet precautions for a
child who has pertussis, also known as whooping cough.
Pertussis is transmitted through contact with infected largedroplet nuclei that are suspended in the air when the child
coughs, sneezes, or talks.
A nurse in an emergency department is caring for a schoolage child who has appendicitis and rates their abdominal pain
as 7 on a scale of 0 to 10. Which of the following actions
should the nurse take? - ...ANSWER...Give morphine
0.05mg/kg IV
Rationale: A pain level of 7 on a scale of 0 to 10 is
considered severe. The nurse should administer an analgesic
medication for pain relief.
A nurse is caring for an adolescent who received a kidney
transplant. Which of the following findings should the nurse
identify as an indication the adolescent is rejecting the
kidney? - ...ANSWER...Serum creatinine 3.0 mg/dL
Rationale: Creatinine is a byproduct of protein metabolism
and is excreted from the body through the kidneys. An
elevated serum creatinine level, therefore, can be an indication
that the kidneys are not functioning. The nurse should identify
that the adolescent's serum creatinine level is higher than the
expected reference range of 0.4 to 1.0 mg/dL for an
adolescent and can indicate rejection of the kidney.
A nurse is proving dietary teaching to the parent of a schoolage child who has celiac disease. The nurse should
recommend that the parent offer which of the following foods
to the child? - ...ANSWER...White rice
Rationale: The nurse should recommend that the parent offer
white rice to the child because it is a gluten-free food. The
nurse should instruct the parent that the child will remain on a
lifelong gluten-free diet and the child should not consume
oats, rye, barley, or wheat, and sometimes lactose deficiency
can be secondary to this disease.
A nurse is caring for a 15 year-old client who is married and
is scheduled for a surgical procedure. The client asks, "who
should sign my surgical consent?" Which of the following
responses should the nurse make? - ...ANSWER..."You can
sign the consent form because you are married."
Rationale: The nurse should inform the adolescent that
marriage gives adolescents the legal right to consent to
surgical procedures and sign other legal documents that they
would not otherwise be able to sign due to their age.
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