The nurse caring for a child who sustained a burn injury plans care based on which pediatric
considerations are associated with this injury? Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of infection for infants and
4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total
body surface area.
5. The lower proportion of body fluid to body mass in a child increases the risk of
6. Infants and young children are at increased risk for protein and calorie deficiency
because they have smaller muscle mass and less body fat than adults.
The nurse is administering mouth care to an unconscious client. The nurse should perform which
actions in the care of this person? Select all that apply.
1. Use products that contain alcohol.
2. Position the client on his or her side.
3. Brush the teeth with a small, soft toothbrush.
4. Cleanse the mucous membranes with soft sponges.
5. Use lemon glycerin swabs when performing mouth care.
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to
note which findings? Select all that apply.
1. Elevated C-reactive protein
2. Elevated antistreptolysin O titer
3. Presence of Reed-Sternberg cell
4. Decreased erythrocyte sedimentation rate
5. Presence of group A beta-hemolytic strep
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are
interventions to aid the client in relieving the spasm? Select all that apply.
4. Muscle relaxers
5. Intermittent traction
The nurse is planning care for a client returning to the nursing unit after a bone biopsy. Which
nursing action would be contraindicated in the postprocedure care for this client?
1. Monitor vital signs.
2. Administer oral analgesics as needed.
3. Place the limb in a dependent position for 24 hours.
4. Monitor biopsy site for swelling, bleeding, or hematoma.
The community nurse is conducting a health promotion program, and the topic of the discussion
relates to the risk factors for gastric cancer. Which item, if identified as a risk factor by a client,
indicates a need for further discussion?
2. A low-fat diet
3. Foods containing nitrates
4. A diet of smoked, highly salted, and spiced foods
The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the
ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the
1. Roast pork
2. Cheese omelet
3. Pasta with sauce
4. Tuna fish sandwich
The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen
chart. After the client’s vision is tested with a Snellen chart, the results of testing are documented
as 20/40. Which statement by the new RN indicates that the teaching has been effective?
1. “The client’s vision is normal, but the client may require reading glasses.”
2. “The client is legally blind, and glasses or contact lenses will not be helpful.”
3. “The client can read at a distance of 40 feet (12 meters) what a person with normal
vision can read at 20 feet (6 meters).”
4. “The client can read at a distance of 20 feet (6 meters) what a person with normal
vision can read at 40 feet (12 meters).”
A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should
the nurse plan to assess the client for a hypoglycemic reaction?
A client has recently begun medication therapy with propranolol. The long-term care nurse
should plan to notify the health care provider (HCP) if which assessment finding is noted?
1. Complaints of insomnia
2. Audible expiratory wheezes
3. Decrease in heart rate from 86 to 78 beats/min
4. Decrease in blood pressure from 162/90 to 136/84 mm Hg