Deck 4: Adult Critical Care Registered Nurse

Question 1

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?

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

Answer 1

anuria within the past 4 hours

Question 2

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:

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

Answer 2

explain that the behavior is expected

Question 3

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:

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

Answer 3

urine output of 30 ml.hour

Question 4

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:

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

Question 5

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:

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

Question 6

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?

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

Question 7

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?

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 8

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?

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 9

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?

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

Question 10

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

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 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?

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

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?

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.