Pediatric nursing revolves around providing care for children from infancy through their late teen years and their families. Let’s test your knowledge about pediatric nursing with questions like calculating pediatric dosage, growth and development, common diseases affecting children and more. This comprehensive 50-item quiz will sharpen your critical thinking skills for the NCLEX sample quiz about Pediatric Nursing.
A person’s a person, no matter how small.
— Dr. Seuss
Topics or concepts included in this exam are:
- Administration of medicine to pediatric clients
- Common diseases among children
- Various questions about pediatric nursing
To make the most out of this quiz, follow the guidelines below:
- Read each question carefully and choose the best answer.
- You are given one minute per question. Spend your time wisely!
- Answers and rationales (if any) are given below. Be sure to read them.
- If you need more clarifications, please direct them to the comments section.
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz. You are given 1 minute per question.
Pediatric Nursing Practice Quiz 1 (50 Questions)
Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
Pediatric Nursing Practice Quiz 1 (50 Questions)
In Text Mode: All questions and answers are given for reading and answering at your own pace. You can also copy this exam and make a print out.
1. Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child’s history, the nurse considers which information to be most important?
A. A fever that started 3 days ago
B. Lack of interest in food
C. A recent episode of pharyngitis
D. Vomiting for 2 days
2. Nurse Analiza is administering a medication via the intraosseous route to a child. Intraosseous drug administration is typically used when a child is:
A. Under age 3
B. Over age 3
C. Critically ill and under age 3
D. Critically ill and over age 3
3. When assessing a child’s cultural background, the nurse in charge should keep in mind that:
A. Cultural background usually has little bearing on a family’s health practices
B. Physical characteristics mark the child as part of a particular culture
C. Heritage dictates a group’s shared values
D. Behavioral patterns are passed from one generation to the next
4. While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
A. Notify the doctor
B. Look for other signs of abuse
C. Recognize this as a normal finding
D. Ask about a family history of Tay-Sachs disease
5. The nurse is aware that the most common assessment finding in a child with ulcerative colitis is:
A. Intense abdominal cramps
B. Profuse diarrhea
C. Anal fissures
D. Abdominal distention
6. When administering an I.M. injection to an infant, the nurse in charge should use which site?
D. Vastus lateralis
7. A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse in charge anticipates that the doctor will order which laboratory test?
A. Total iron-binding capacity
C. Total protein
D. Serum transferrin
8. When developing a plan of care for a male adolescent, the nurse considers the child’s psychosocial needs. During adolescence, psychosocial development focuses on:
A. Becoming industrious
B. Establishing an identity
C. Achieving intimacy
D. Developing initiative
9. When developing a plan care for a hospitalized child, nurse Mica knows that children in which age group is most likely to view illness as a punishment for misdeeds?
B. Preschool age
C. School age
10. Nurse Sunshine suspects that a child, age 4, is being neglected physically. To best assess the child’s nutritional status, the nurse should ask the parents which question?
A. “Has your child always been so thin?”
B. “Is your child a picky eater?”
C. “What did your child eat for breakfast?”
D. “Do you think your child eats enough?”
11. A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?
A. Heart rate, respiratory rate, and blood pressure
B. Recent exposure to communicable diseases
C. Number of immunizations received
D. Height and weight
12. A mother asks the nurse how to handle her 5-year-old child, who recently started wetting the pants after being completely toilet trained. The child just started attending nursery school 2 days a week. Which principle should guide the nurse’s response?
A. The child forgets previously learned skills
B. The child experiences growth while regressing, regrouping, and then progressing
C. The parents may refer less mature behaviors
D. The child returns to a level of behavior that increases the sense of security.
13. A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child’s vision, the nurse should ask:
A. “Do you have any problems seeing different colors?”
B. “Do you have trouble seeing at night?”
C. “Do you have problems with glare?”
D. “How are you doing in school?”
14. During a well-baby visit, Liza asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first?
B. Egg whites
C. Rice cereal
15. To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine (Anectine) is used with which of the following agents?
16. A 1-year-and 2-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the patient’s room, the nurse anticipates using which traction system?
A. Bryant’s traction
B. Buck’s extension traction
C. Overhead suspension traction
D. 90-90 traction
17. Hannah, age 12, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is least effective?
A. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model
B. Initiating a teenage parent support group with first – and – second-time mothers
C. Using audiovisual aids that show discussions of feelings and skills
D. Providing age-appropriate reading materials
18. When performing a physical examination on an infant, the nurse in charge notes abnormally low-set ears. This finding is associated with:
A. Otogenous tetanus
B. Tracheoesophageal fistula
C. Congenital heart defects
D. Renal anomalies
19. Nurse Walter should expect a 3-year-old child to be able to perform which action?
A. Ride a tricycle
B. Tie the shoelaces
D. Jump rope
20. Nurse Kim is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?
A. Eustachian tubes
C. Tympanic membrane
D. External ear canal
21. The nurse is evaluating a female child with acute post streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement?
A. Increased urine output
B. Increased appetite
C. Increased energy level
D. Decreased diarrhea
22. Dr. Jones prescribes corticosteroids for a child with nephritic syndrome. What is the primary purpose of administering corticosteroids to this child?
23. Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
A. A sunken fontanel
B. Decreased pulse rate
C. Increased blood pressure
D. Low urine specific gravity
24. How should the nurse prepare a suspension before administration?
A. By diluting it with normal saline solution
B. By diluting it with 5% dextrose solution
C. By shaking it so that all the drug particles are dispersed uniformly
D. By crushing remaining particles with a mortar and pestle
25. What should be the initial bolus of crystalloid fluid replacement for a pediatric patient in shock?
A. 20 ml/kg
B. 10 ml/kg
C. 30 ml/kg
D. 15 ml/kg
26. Lily , age 5, with an intelligence quotient of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is:
A. Within the lower range of normal intelligence
B. Mildly retarded but educable
C. Moderately retarded but trainable
D. Completely dependent on others for care
27. Mandy, age 12, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child’s nutritional intake, the nurse should ask:
A. “What activities do you engage in during the day?”
B. “Do you have any allergies to foods?”
C. “Do you like yourself physically?”
D. “What kinds of food do you like to eat?”
A. At 1 to 2 years of age
B. At I week to 1 year of age, peaking at 2 to 4 months
C. At 6 months to 1 year of age, peaking at 10 months
D. At 6 to 8 weeks of age
29. When evaluating a severely depressed adolescent, the nurse knows that one indicator of a high risk for suicide is:
30. A child is diagnosed with Wilms’ tumor. During assessment, the nurse in charge expects to detect:
31. Which of the following would be inappropriate when administering chemotherapy to a child?
A. Monitoring the child for both general and specific adverse effects
B. Observing the child for 10 minutes to note for signs of anaphylaxis
C. Administering medication through a free-flowing intravenous line
D. Assessing for signs of infusion infiltration and irritation
32. Which of the following is the best method for performing a physical examination on a toddler
A. From head to toe
B. Distally to proximally
C. From abdomen to toes, the to head
D. From least to most intrusive
33. Which of the following organisms is responsible for the development of rheumatic fever?
A. Streptococcal pneumonia
B. Haemophilus influenza
C. Group A β-hemolytic streptococcus
D. Staphylococcus aureus
D. Low blood pressure
35. How does the nurse appropriately administer Mycostatin suspension in an infant?
A. Have the infant drink water, and then administer myostatin in a syringe
B. Place Mycostatin on the nipple of the feeding bottle and have the infant suck it
C. Mix Mycostatin with formula
D. Swab Mycostatin on the affected areas
36. A mother tells the nurse that she is very worried because her 2-year old child does not finish his meals. What should the nurse advise the mother?
A. make the child seat with the family in the dining room until he finishes his meal
B. provide quiet environment for the child before meals
C. do not give snacks to the child before meals
D. put the child on a chair and feed him
A. uneven head shape
B. respirations are irregular, abdominal, 30-60 bpm
c. (+) Moro reflex
D. heart rate is 80 bpm
38. Which of the following situations increase the risk of lead poisoning in children?
A. playing in the park with heavy traffic and with many vehicles passing by
B. playing sand in the park
C. playing plastic balls with other children
D. playing with stuffed toys at home
39. An inborn error of metabolism that causes a premature destruction of RBC?
D. Celiac Disease
40. Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia?
A. Increased hemoglobin
B. Normal hematocrit
C. Decreased mean corpuscular volume (MCV)
D. Normal total iron-binding capacity (TIBC)
41. The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
A. The nurse should insert a padded tongue blade in the patient’s mouth to prevent the child from swallowing or choking on his tongue.
B. The nurse should help the mother restrain the child to prevent him from injuring himself.
C. The nurse should call the operator to page for seizure assistance.
D. The nurse should clear the area and position the client safely.
42. At the community center, the nurse leads an adolescent health information group, which often expands into other areas of discussion. She knows that these youths are trying to find out “who they are,” and discussion often focuses on which directions they want to take in school and life, as well as peer relationships. According to Erikson, this stage is known as:
A. identity vs. role confusion.
B. adolescent rebellion.
C. career experimentation.
D. relationship testing
43. The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern?
A. The baby cannot say “mama” when he wants his mother.
B. The mother has not given him finger foods.
C. The child does not sit unsupported.
D. The baby cries whenever the mother goes out.
44. Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter’s immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:
A. 12 months.
B. 15 months.
C. 10 months.
D. 14 months.
45. Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:
A. Prone for two hours to prevent aspiration, should she vomit.
B. Semi-Fowler’s so she can watch TV for five hours and be entertained.
C. Supine for several hours, to prevent a headache.
D. On her right sides to encourage return of CSF
A. every shift.
B. every day.
C. every 4 hours.
D. every 15 minutes.
47. Kim is using bronchodilators for asthma. The side effects of these drugs that you need to monitor this patient for include:
A. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.
B. tachycardia, headache, dyspnea, temp. 101 F, and wheezing.
C. blurred vision, tachycardia, hypertension, headache, insomnia, and oliguria.
D. restlessness, insomnia, blurred vision, hypertension, chest pain, and muscle weakness.
48. The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test:
A. blood culture.
B. throat and ear culture.
C. CAT scan.
D. lumbar puncture.
49. The nurse is drawing blood from the diabetic patient for a glycosylated hemoglobin test. She explains to the woman that the test is used to determine:
50. The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
A. capillary refill.
B. radial and ulnar pulse.
C. finger movement
D. skin integrity
Answers and Rationale
1. Answer: C. A recent episode of pharyngitis
A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.
2. Answer: C. Critically ill and under age 3
In an emergency, intraosseous drug administration is typically used when a child is critically ill and under age 3.
3. Answer: D. Behavioral patterns are passed from one generation to the next
A family’s behavioral patterns and values are passed from one generation to the next.
- Option A: Cultural background commonly plays a major role in determining a family’s health practices.
- Option B: Physical characteristics do not indicate a child’s culture.
- Option C: Although heritage plays a role in culture, it does not dictate a group’s shared values and its effect on culture is weaker than that of behavioral patterns.
4. Answer: A. Notify the doctor
Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate abuse and is not associated with Tay-Sachs disease.
5. Answer: B. Profuse diarrhea
Ulcerative colitis causes profuse diarrhea, intense abdominal cramps, anal fissures, and abdominal distensions are more common in Crohn’s disease.
6. Answer: D. Vastus lateralis
The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles.
- Option A: The deltoid is inappropriate.
- Options B and C: The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.
7. Answer: C. Total protein
A negative nitrogen balance may result from inadequate protein intake and is best detected by measuring the total protein level.
- Options A, B, and C: Measuring total iron-binding capacity, hemoglobin, and serum transferrin levels would help detect iron-deficiency anemia, not a negative nitrogen balance.
8. Answer: B. Establishing an identity
According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers and strives to attain a personal identity by becoming more independent from the family.
- Option A: Becoming industrious is the developmental task of the school-age child.
- Option C: Achieving intimacy is the task of the young adult.
- Option D: Developing initiative is the task of the preschooler.
9. Answer: B. Preschool age
Preschool-age children are most likely to view illness as a punishment for misdeeds. Option A: Separation anxiety, although seen in all age group, is most common in older infants.
- Option A: Separation anxiety, although seen in all age group, is most common in older infants.
- Options C and D: Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
10. Answer: C. “What did your child eat for breakfast?”
The nurse should obtain objective information about the child’s nutritional intake, such as by asking about what the child ate for a specific meal. The other options ask for subjective replies that would be open to interpretation.
11. Answer: A. Heart rate, respiratory rate, and blood pressure
The most important data to obtain on a child’s arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.
12. Answer: D. The child returns to a level of behavior that increases the sense of security.
The stress of starting nursery school may trigger a return to a level of successful behavior from earlier stages of development.
- Option A: A child’s skills remain intact, although increased stress may prevent the child from using these skills.
- Option B: Growth occurs when the child does not regress.
- Option C: Parents rarely desire less mature behaviors.
13. Answer: D. “How are you doing in school?”
A child’s poor progress in school may indicate a visual disturbance. The other options are more appropriate questions to ask when assessing vision in a geriatric patient.
14. Answer: C. Rice cereal
Rice cereal is the first solid food an infant should receive because it is easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and finally, meat.
- Option B: Egg whites should not be given until age 9 months because they may trigger a food allergy.
15. Answer: C. Atropine sulfate
Succinylcholine is an ultra-short-acting depolarizing agent used for rapid-sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice in treating succinylcholine-induced bradycardia.
- Options A and B: Epinephrine bolus and isoproterenol are not used in rapid-sequence intubation because of their profound cardiac effects.
- Option D: Lidocaine is used in adults only.
16. Answer: A. Bryant’s traction
Bryant’s traction is used to treat femoral fractures of congenital hip dislocation in children under age 2 who weigh less than 30 lb (13.6 kg).
- Option B: Buck’s extension traction is skin traction used for short-term immobilization or to correct bone deformities or contractures.
- Option C: Overhead suspension traction is used to treat fractures of the humerus; and
- Option D: 90-90 traction is used to treat femoral fracture in children over age 2.
17. Answer: D. Providing age-appropriate reading materials
Because adolescents absorb less information through reading, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent.
- Options A, B, and C: The other options engage more than one of the senses and therefore serve as effective teaching strategies.
18. Answer: D. Renal anomalies
Normally the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation.
- Options A, B, and C: Low-set ears do not accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.
19. Answer: A. Ride a tricycle
At age 3, gross motor development and refinement in eye-hand coordination enable a child to ride a tricycle.
- Options B, C, and D: The fine motor skills required to tie shoelaces and the gross motor skills require for roller-skating and jumping rope develop around age 5.
20. Answer: A. Eustachian tubes
In a child, Eustachian tubes are short and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media.
- Options B, C, and D: The nasopharynx, tympanic membrane, external ear canal have no unusual features that would predispose a child to otitis media.
21. Answer: A. Increased urine output
Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post streptococcal glomerulonephritis (APSGN) is improving.
- Options B, C, and D: Increased appetite, an increased energy level, and decreased diarrhea are not specific to APSGN.
22. Answer: C. To decrease proteinuria
The primary purpose of administering corticosteroids to a child with nephritic syndrome is to decrease proteinuria.
- Option A: Corticosteroids have no effect on blood pressure.
- Option B: Although they help reduce inflammation, this is not the reason for their use in patients with nephritic syndrome.
- Option D: Corticosteroids may predispose a patient to infection.
23. Answer: A. A sunken fontanel
In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.
24. Answer: C. By shaking it so that all the drug particles are dispersed uniformly
The nurse should shake a suspension before administration to dispersed drug particles uniformly.
- Options A, B, and D: Diluting the suspension and crushing particles are not recommended for this drug form.
25. Answer: A. 20 ml/kg
Fluid volume replacement must be calculated to the child’s weight to avoid over-hydration. Initial fluid bolus is administered at 20 ml/kg, followed by another 20 ml/kg bolus if there is no improvement in fluid status.
26. Answer: B. Mildly retarded but educable
According to the American Association on Mental Deficiency, a person with an intelligence quotient (IQ) between 50 and 70 is classified as mildly mentally retarded but educable.
- Option C: One with an IQ between 35 and 50 is classified as moderately retarded but trainable.
- Option D: One with an IQ below 36 is severely and profoundly impaired, requiring custodial care.
27. Answer: C. “Do you like yourself physically?”
Role and relationship patterns focus on body image and the patient’s relationship with others, which commonly interrelated with food intake.
- Options A and C: Questions about activities and food preferences elicit information about health promotion and health protection behaviors.
- Option B: Questions about food allergies elicit information about health and illness patterns.
28. Answer: B. At I week to 1 year of age, peaking at 2 to 4 months
SIDS can occur any time between 1 week and 1 year of age. The incidence peaks at 2 to 4 months of age.
29. Answer: D. A preoccupation with death
An adolescent who demonstrates a preoccupation with death (such as by talking about death frequently) should be considered at high risk for suicide.
- Options A, B, and C: Although depression, excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents; they also occur in adolescents who are not suicidal.
30. Answer: D. An abdominal mass
The most common sign of Wilms’ tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth.
- Option A: Gross hematuria is uncommon, although microscopic hematuria may be present.
- Option B: Dysuria is not associated with Wilms’ tumor.
- Option C: Nausea and vomiting are rare in children with Wilms’ tumor.
31. Answer: B. Observing the child for 10 minutes to note for signs of anaphylaxis
When administering chemotherapy, the nurse should observe for an anaphylactic reaction for 20 minutes and stop the medication if one is suspected. Chemotherapy is associated with both general and specific adverse effects, therefore close monitoring for them is important.
32. Answer: D. From least to most intrusive
When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive.
- Option A: Starting at the head or abdomen is intrusive and should be avoided.
- Option B: Proceeding from distal to proximal is inappropriate at any age.
33. Answer: C. Group A β-hemolytic streptococcus
Rheumatic fever results from a delayed reaction to inadequately treated group A β-hemolytic streptococcal infection.
34. Answer: A. Polycythemia
The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation
35. Answer: D. Swab Mycostatin on the affected areas
Mycostatin suspension is given as swab. Never mix medications with food and formula.
36. Answer C. do not give snacks to the child before meals
If the child is hungry he/she more likely would finish his meals. Therefore, the mother should be advised not to give snacks to the child. The child is a “busy toddler.” He/she will not able to keep still for a long time.
37. Answer D. heart rate is 80 bpm
Normal heart rate of the newborn is 120 to 160 bpm.
- Options A, B, and C are normal assessment findings (uneven head shape is molding).
38. Answer: A. playing in the park with heavy traffic and with many vehicles passing by
Lead poisoning may be caused by inhalation of dust and smoke from leaded gas. It may also be caused by lead-based paint, soil, water (especially from plumbings of old houses).
39. Answer: A. G6PD
Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessive hereditary disease characterised by abnormally low levels of glucose-6-phosphate dehydrogenase (abbreviated G6PD or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.
40. Answer: C. Decreased mean corpuscular volume (MCV)
For the child with iron deficiency anemia, the blood study results most likely would reveal decreased mean corpuscular volume (MCV) which demonstrates microcytic anemia, decreased hemoglobin, decreased hematocrit and elevated total iron binding capacity.
41. Answer: D. The nurse should clear the area and position the client safely.
The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself.
42. Answer: A. identity vs. role confusion.
During this period, which lasts up to the age of 18-21 years, the individual develops a sense of “self.” Peers have a major big influence over behavior, and the major decision is to determine a vocational goal.
43. Answer: C. The child does not sit unsupported.
Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say “mama” in the sense that it refers to their mother at this time.
44. Answer: A. 12 months.
By 12 months, 50 percent of children can walk well.
45. Answer: C. supine for several hours, to prevent a headache.
Lying flat keeps the patient from having a “spinal headache.” Increasing the fluid intake will assist in replenishing the lost fluid during this time.
46. Answer: C. every 4 hours.
The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.
47. Answer: A. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.
Bronchodilators can produce the side effects listed in answer choice (A) for a short time after the patient begins using them.
48. Answer: D. lumbar puncture.
49. Answer: C. glucose levels over the past several months.
The glycosylated hemoglobin test measures glucose levels for the previous 3 to 4 months.
50. Answer: D. skin integrity
Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important.
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