Question 1

A patient comes to the Cardiovascular Care Unit with a blood pressure of 94/68, a heart rate of 124 and chest pain rated as 8/10. The patient has already taken one 0.04 mg tablet of Nitroglycerin five minutes ago. What should the nurse do next?

Accepted Answer

A)  Take the patient's blood pressure and put them on the monitor.
B)  Administer a dose of Morphine 2 mg IV and re-assess pain.
C)  Obtain a stat EKG.
D)  Administer another dose of 0.04 mg tablet of Nitroglycerin. D

Question 2

A mother of a 12-month-old girl asks the nurse what toys she should buy her child at this stage. Based on her understanding about the normal growth and development of a child, the nurse would suggest which of the following toys?

Accepted Answer

A)  Rattles
B)  Rubber ring
C)  Pots and pans
D)  Bright-colored mobiles C

Question 3

On assessment, the nurse notes that a 10-month-old child searches for and retrieves toys that disappear from view. Based on Piaget's stages of cognitive development, the nurse would recommend which of the following toys or games?

Accepted Answer

A)  Rattle
B)  Nesting toys
C)  Peek-a-boo
D)  Throw and retrieve B

Question 4

A nurse is teaching a mother with a new baby about car seats. Which of the following, if stated by the client, indicates that further teaching is needed?

Accepted Answer

A)  "Infant-only car seats are the most recommended type of car seats for infants."
B)  "My child has to be in a car seat until the child reaches 40 to 60 pounds."
C)  "My child has to be placed in a car seat that is facing the rear in the back seat until my child is about 20 lbs."
D)  "My child has to be placed in a car seat until the school-age years"

Question 5

The nurse is caring for a 12 year-old on admission to the isolation unit. One assessment parameter that will indicate that the child has adequate fluid replacement would be:

Accepted Answer

A)  urine output of 30 ml.hour
B)  absence of thirst
C)  increased level of hct
D)  good skin turgor around the area of burn

Question 6

A nurse is assessing an 18-month-old child. The nurse would expect the child to do which of the following actions?

Accepted Answer

A)  Stack 2 blocks
B)  Run and jump in place
C)  Open doors by turning doorknobs
D)  Climbs the stairs alone, with both feet on the same step at the same time

Question 7

A mother brings her 26 month-old to the well-child clinic. She expresses frustration due to her baby's constantly saying "NO" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need:

Accepted Answer

A)  independence
B)  initiative
C)  self-esteem
D)  role confusion

Question 8

Nurse Beyonce is caring for a 20 lbs, 6 month-old with a 3 day history of loose watery stool, vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 40 ml/hr. Which finding should be reported to the health care provider immediately?

Accepted Answer

A)  3 episodes of vomiting within a period of an hour
B)  crying and irritability
C)  sucking on a pacifier too vigorously
D)  anuria within the past 4 hours

Question 9

A 16 month-old child was admitted to the pediatric unit. The nurse assigned to this child enters the child's room for the first time; the toddler suddenly runs to the mother and begins to cry. The nurse would initially:

Accepted Answer

A)  explain that the behavior is expected
B)  discuss appropriate use of time out
C)  advise mother that child needs extra attention
D)  try to change the plan of care

Question 10

A mother asks the nurse how she can prevent her child from developing recurrent otitis media. The nurse's best response is which of the following?

Accepted Answer

A)  "Increase the child's fluid intake if she's experiencing common colds."
B)  "Cover the child's ear when bathing."
C)  "Feed the child on his back."
D)  "Administer nose drops before bedtime"

Question 11

The nurse is developing a teaching plan for a patient who just received an inserted permanent pacemaker. Which of the following concepts should the nurse teach the patient?

Accepted Answer

A)  Advise the patient to avoid tight clothing
B)  It is okay to resume all physical activities
C)  Avoid computerized tomography (CT)  scans
D)  Hiccups can be normal for a few days after pacemaker insertion

Question 12

Nurse Tammy is caring for a 3 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. Tammy recognizes this problem is probably due to:

Accepted Answer

A)  cerebral vascular accident
B)  meningitis occure postoperatively
C)  reaction due to medications
D)  metabolic alkalosis

Exam 4: Adult Critical Care Registered Nurse