SAFETY AND INFECTION CONTROL
1.
The parents of a 6-year-old child visit the community health clinic for a school readiness check-up. They ask the nurse what developmental behaviors they should expect as their child begins school. Which statement best describes a typical characteristic of a child at this age?
2.
An 8-month-old infant is being discharged after hospitalization for gastroenteritis and dehydration. While teaching the parents about proper diet and fluid needs during recovery, the nurse should also include teaching about which additional topic?
3.
Nurse Betina is conducting a routine health assessment for a toddler during a well-child visit. She plans to begin screening for lead poisoning as part of preventive care. At what age should Nurse Betina initiate lead screening for the child?
4.
An 11-month-old infant is admitted with dehydration secondary to prolonged diarrhea. The laboratory results indicate metabolic acidosis. During the assessment, which clinical manifestation should the nurse expect to observe?
5.
The nurse is teaching the parents of a 5-year-old child recently diagnosed with celiac disease about appropriate dietary restrictions before discharge. Which statement by the parents indicates that they have understood the teaching?
6.
A parent brings their 19-month-old toddler to the clinic for a routine health check-up. During the physical examination, the nurse palpates the child’s fontanels. Which finding should the nurse expect at this age?
7.
Patrick, a healthy adolescent, is hospitalized with meningitis and is receiving both intravenous and oral fluids. The nurse carefully monitors his fluid intake. Fluid overload in this client may lead to which complication?
8.
A 9-month-old infant is admitted to the pediatric ward with a diagnosis of nonorganic failure to thrive. The nurse develops a plan of care to promote bonding and improve nutritional status. Which nursing action is most appropriate for this infant?
9.
The mother of Gian, a 4-year-old preschooler with spina bifida, tells the nurse that her child develops sneezing and a rash when playing with brightly colored balloons and recently had allergic reactions after eating kiwifruit and bananas. Based on this information, the nurse should suspect an allergy to which substance?
10.
Cristina, the mother of a 4-year-old child, tells the nurse during a clinic visit that her child is a very poor eater and often refuses meals. What is the nurse’s best recommendation to help improve the child’s nutritional intake?
11.
Nurse Roy is caring for a 10-year-old child who is receiving total parenteral nutrition (TPN) through a peripheral IV line. To ensure vein safety while still providing adequate nutrition, what is the minimum glucose concentration that can be safely administered through this route?
12.
David, a 15-month-old toddler, is recovering in the pediatric unit after surgery for removal of a Wilms’ tumor. The nurse assesses him for pain during the postoperative period. Which finding best indicates that David is free from pain?
13.
An 8-year-old boy with Down syndrome is admitted to the pediatric unit for a routine health evaluation. The nurse is developing a plan of care to promote his development and well-being. Which nursing action is most appropriate?
14.
Nurse Vincent is conducting a health teaching session for the parents of a school-age child during a community clinic visit. To promote the child’s safety and development, which teaching topic should the nurse prioritize?
15.
At the end of her shift on the pediatric unit, the nurse is preparing to hand over the care of her assigned patients to the incoming nurse. Which action should take top priority before leaving?
16.
Nurse Harry finds a 4-year-old child unresponsive and without a pulse. He immediately begins cardiopulmonary resuscitation (CPR). Which action should the nurse perform to deliver effective chest compressions for this child?
17.
A 4-month-old infant is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. The nurse is preparing to initiate care for the infant. Which nursing intervention should be the highest priority at this time?
18.
Shane, the mother of a 22-month-old toddler, tells the nurse that she wants to start toilet training her child. The nurse discusses the process and emphasizes that which factor is the most important for successful toilet training?
19.
An infant who has been in foster care since birth is admitted to the hospital and requires a blood transfusion. The nurse prepares to obtain informed consent for the procedure. Who is legally authorized to provide written consent?
20.
A 7-year-old child diagnosed with acute leukemia is undergoing remission induction chemotherapy. The regimen includes allopurinol along with cytotoxic drugs. The nurse understands that the primary purpose of giving allopurinol is to:
21.
A 10-year-old girl who recently returned from overseas travel is admitted with a diagnosis of Severe Acute Respiratory Syndrome (SARS). The nurse prepares to provide direct care and must wear appropriate personal protective equipment (PPE). Based on the mode of transmission, which PPE should the nurse use?
22.
A high-risk adolescent receives a tuberculin (Mantoux) skin test during a school health screening to check for tuberculosis (TB) infection. The nurse explains when the test site should be checked for a reaction. After how many hours should the result be evaluated?
23.
Nurse Oliver is counseling a mother who plans to stop breastfeeding her 5-month-old infant. The mother asks which foods she should begin adding to her baby’s diet. Which recommendation should the nurse give?
24.
Gracie, the mother of a 3-month-old infant, calls the clinic concerned that her baby has developed a diaper rash. She asks the nurse what she should do to help relieve it. Which advice should the nurse provide?
25.
Nurse Kelly is teaching the parents of a 2-year-old child about safety and emergency care for accidental poisoning at home. She asks what they would do first if their child ingested an unknown substance. Which action should the nurse emphasize as most important?
26.
A 6-year-old child is brought to the emergency department with third-degree burns on the hands, face, and chest after a house fire. The nurse begins the initial assessment and care. Which nursing diagnosis should take top priority?
27.
A 3-year-old child is admitted with dehydration and is receiving Dextrose 5% in water with half-normal saline at a rate of 100 mL/hour. During assessment, the nurse suspects fluid overload. Which sign or symptom would best indicate excessive I.V. fluid intake?
28.
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation
29.
Nurse Mariane is caring for a 2-month-old infant diagnosed with spina bifida. During routine assessment, the nurse wants to monitor for signs of developing hydrocephalus, a common complication. Which technique is most important for early recognition?
30.
An adolescent who recently sustained a tibia fracture in a motor vehicle accident is now in a long leg cast. The patient complains of severe itching under the cast and asks the nurse what can be done for relief. Which nursing action is most appropriate?
31.
A 6-year-old child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. The child is febrile, irritable, and sensitive to light. Which nursing action should the nurse perform first?
32.
A 56-year-old client is admitted to the hospital with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. The nurse is preparing to assign isolation precautions. Which type of isolation is most appropriate for this client?
33.
A 48-year-old client is admitted to the medical ward with respiratory symptoms. The nurse is reviewing the admission diagnoses of all clients. For which condition should the nurse initiate airborne precautions?
34.
A nurse in a medical-surgical unit is preparing to provide care for several clients. To prevent the spread of infection, which of the following actions should the nurse consider the first priority?
35.
A 32-year-old woman is admitted to an isolation unit after being diagnosed with pulmonary tuberculosis during a pre-employment physical. She is anxious to cooperate with treatment and asks the nurse how TB spreads from one person to another. The nurse should explain that the most common mode of transmission is through:
36.
A 2-year-old boy is being admitted to the pediatric unit with a diagnosis of febrile seizures following a high fever at home. In preparing for his admission, which of the following nursing actions is most important?
37.
A 25-year-old man recovering from second- and third-degree burns over 25% of his body is preparing for discharge. The nurse reviews his home wound care instructions. Which statement by the client indicates that he has understood the teaching?
38.
An 85-year-old man underwent surgery for benign prostatic hypertrophy (BPH). Before surgery, he was alert and cooperative, but several hours postoperatively, the nurse finds him confused, agitated, and attempting to climb over the bed rails. Which nursing intervention is most appropriate to calm the client?
39.
Ms. Smith, a 52-year-old woman diagnosed with cervical cancer, is admitted for internal radiation therapy (brachytherapy). The nurse reviews the procedure with her. Which statement by the client the night before the procedure indicates she understands the teaching?
40.
The nurse in charge is conducting rounds to evaluate infection control practices on the medical-surgical unit. Which observation indicates a break in aseptic technique and the need for staff re-education?
41.
The charge nurse observes a new staff nurse changing the dressing on a postoperative wound. After washing her hands, the nurse dons sterile gloves to remove the old dressing, then removes the gloves and dons a new pair of sterile gloves to clean and redress the wound. What is the most appropriate action for the charge nurse to take?
42.
Mrs. Jones, a 58-year-old woman recovering from a right leg wound, is instructed to change her sterile dressing twice daily using 4x4 gauze, normal saline, and abdominal pads. Which statement by Mrs. Jones best indicates she understands the importance of asepsis?
43.
A client diagnosed with hepatitis B has been placed under blood and body fluid isolation. The nurse is teaching the nursing assistant about proper precautions. Which statement by the assistant indicates the best understanding of the correct protocol?
44.
A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
45.
The nurse supervisor is observing nonprofessional staff during patient care to evaluate their understanding of universal precautions for preventing HIV transmission. Which staff behavior indicates correct application of these precautions?
46.
Jayson, a 1-year-old child, is being treated for a staphylococcal skin infection. A few days later, his older brother develops the same type of infection. Which behavior by the children most likely caused the transmission of the organism?
47.
Jessie, a 28-year-old man recently diagnosed with acquired immune deficiency syndrome (AIDS), is preparing for hospital discharge. The nurse evaluates his understanding of AIDS transmission prevention. Which statement by Jessie indicates that the teaching has been effective?
48.
A 35-year-old man is admitted with fatigue, weight loss, and recurrent infections. The nurse suspects AIDS and begins collecting a health history. Which of the following questions would be least useful in assessing this client?
49.
Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted one day before her scheduled eye surgery. The nurse is developing her preoperative care plan. Which of the following goals should the nurse include as a priority for Mrs. Parker?
50.
A 7-year-old child with acute lymphocytic leukemia (ALL) is undergoing remission induction chemotherapy. The nurse notes that allopurinol is prescribed along with the chemotherapy drugs. The nurse understands that the main purpose of administering allopurinol is to:
