ENPC 6TH EDITION EXAMS 2024 , Exams of Nursing

Download ENPC 6TH EDITION EXAMS 2024 and more Exams Nursing in PDF only on Docsity! 1 | P a g e ENPC 6TH EDITION EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED ANSWERS BY EXPERTS |FREQUENTLY TESTED QUESTIONS AND SOLUTIONS |ALREADY GRADED A+|NEWEST |GUARANTEED PASS|LATEST UPDATE A 4-year-old child with a history of the flu has a heart rate of 80 beats/minute, respirations of 16 breaths/minute, and capillary refill of more than 3 seconds. The proper sequence for nursing interventions would be: A. Position the airway, administer 100% oxygen, obtain venous access, and administer 20 ml/kg of an isotonic solution. B. Administer 100% oxygen, obtain venous access, administer 0. 1 mg/kg of epinephrine 1:10,000, and prepare for endotracheal intubation. C. Position the airway, provide bag-mask ventilation, provide synchronized cardioversion, and provide supplemental warmth. D. Administer 100% oxygen, prepare for a venous cutdown, administer 20 ml/kg of an isotonic solution, and obtain a chest x-ray. A. Position the airway, administer 100% oxygen, obtain venous access, and administer 20 ml/kg of an isotonic solution. A 3-year-old is transported by prehospital personnel after being struck by a car. The parents are en route. The child is screaming and uncooperative. Which is the best approach while conducting the secondary survey? A. Hold the child to comfort him. B. Wait for the parent's arrival. C. Observe for behavioral pain cues. D. Use a doll to demonstrate the examination. C. Observe for behavioral pain cues. Which ocular finding is associated with child maltreatment? A. Glaucoma. B. Conjunctivitis. C. Iritis. D. Retinal hemorrhage. 2 | P a g e Retinal hemorrhage. A pregnant 18-year-old woman arrives at the emergency department about ready to deliver a full-term infant. She states that she noticed a large amount of dark green fluid the last time she went to the bathroom. During the delivery, the nurse should prepare to: A. Dry and arm the infant as soon as is it delivered. B. Stimulate and ventilate the infant immediately after delivery. C. Suction the mouth and nose of the infant while on the perineum. D. Administer blow-by oxygen and rub the back immediately after delivery. Suction the mouth and nose of the infant while on the perineum A 4-year-old presents with vomiting, lethargy, frequent urination, weight loss, and dry mucous membranes. Vital signs reveal deep respirations at 44 breaths per minute, BP of 70/44 mm Hg, and HR of 144 beats per minute. Which of the following laboratory values would be most expected in this child? Low pH level A teenager presents to the ED for evaluation of pain with deep inspiration. The pain was a sudden onset after running track at school. While obtaining the history, the patient states that they have Marfan Syndrome. What would be a priority triage question based on this information? "Have you ever had a pneumothorax?" A 6-week-old is brought to the emergency department by the caregivers for poor feeding, listlessness, and fever. Assessment reveals a crying infant, HR 160 beats/minute, RR 52 breaths/minute, rectal temperature of 96.0 F (35.5 C), and a bulging anterior fontanel. Capillary refill is 4 seconds. Based on these findings what is the most likely diagnostic test the nurse should anticipate? Lumbar puncture A 6-month-old arrives with swelling to the left thigh. Caregivers deny any traumatic event. Assessment findings include a patient who is active and alert, in the 10th percentile for length, and has blue-grey sclera. Radiographs reveal a midshaft fracture of the left femur. Which of the following is the most likely cause? Osteogenesis imperfecta Which of the following is considered a "red flag" when triaging a pediatric patient? A 3-week-old with a temperature of 38.2°C (100.7°F) A 4-year-old patient is being assessed for a foreign body in the nose. The child is awake and alert and watching a video on the caregivers phone. Vitals include HR of 110 beats/minute, RR of 26 breaths per minute, BP of 138/90 mm Hg, and T of 37.3oC (99.3oF) orally. Which of the following interventions should the nurse perform next? 5 | P a g e The nurse is triaging an infant brought to the emergency department by their caregiver. Which finding by the nurse leads the infant to be placed in isolation? Purpuric rash A 5-year-old patient presents with severe dehydration and signs of shock due to viral gastroenteritis. Which of the following physiologic responses by this patient will have the greatest impact on improving their cardiac output? Pediatric patients have strong compensatory mechanisms that attempt to counteract the cardiovascular effects of hypovolemic shock. In children, the heart rate increases to increase preload and cardiac output. Systemic vasoconstriction from epinephrine and norepinephrine release increases afterload. A 3-year-old has a two-day history of runny nose, low-grade fever, and a "barky" cough at night. The child is awake and alert with noted stridor. Pulse oximetry is 96% on room air. Which of the following interventions would be the most appropriated for this child? Administration of nebulized epinephrine A 15-year-old presents alone requesting care. Which of the following chief complaints would most likely be considered legal or appropriate to treat without parental consent? Local and state laws must be followed but generally speaking, pregnancy issues can be treated without parental consent if the minor refuses contact with their family. Other issues that may be treated without parental consent include contraceptive needs, mental health issues, prenatal care, sexually transmitted diseases, and substance use request for help. Minors may be considered "emancipated" if they are living on their own, pregnant or already a parent, in the military, or married. Laws vary and must be followed in each locale. A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after eating lunch. Which of the following is the priority intervention? Intramuscular epinephrine A 3-year-old child who was found in a pool unresponsive has return of spontaneous circulation (ROSC) after prolonged resuscitation. Intubation was performed in the field. Upon arrival to the ED, which intervention is of highest priority? Auscultate breath sounds over the epigastrium and lung fields. You are discharging a patient home who has a history of depression. Discharge teaching should include which of the following? Ensuring all firearms in the home are locked up with no access available by the patient. A 12-year-old restrained, back -seat passenger involved in a motor vehicle crash is noted to have hypotension, tachycardia, and contusions and discoloration across the lap area. On exam a splenic rupture is suspected. Which of the following diagnoses should be suspected as a companion injury with these findings and associated mechanism of injury? 6 | P a g e A Chance fracture (fracture of the lumbar spine) is often associated with belted passengers. Injuries associated with the "seatbelt sign" are small bowel, abdominal vasculature, ureteral, and splenic and liver injuries. A 12-year-old complains of a severe headache for the past 8 hours. Which of the following past history disease processes would be considered a "red flag" and warrant immediate evaluation for this patient? Sickle cell disease A school-aged child arrives in the emergency department with a 2-day history of vomiting. The child is cool and pale, with weak pulses, elevated heart rate, and capillary refill of 4 to 5 seconds. Which of the following is the priority intervention for the child? Initiate a fluid bolus During your primary assessment of a 3-year-old, the child is pale, with a respiratory rate of 70 breaths/minute, costal retractions, poor air movement, and a pulse oximetry reading of 89%. What is the priority intervention for this patient? Administer oxygen per protocol A 5-year-old child presents with hives, swelling of the lips and face, and stridor that developed about an hour after eating lunch. The child has no known allergies. Which of the following is the priority intervention? Administer intramuscular epinephrine An 8-month-old arrives with a 12-hour history of intermittent abdominal pain, non-bilious vomiting, and a low grade fever. On assessment the child is intermittently inconsolable followed by periods of normal activity. A sausage-shaped mass is noted during palpation of the abdomen. The nurse should prepare for which of the following? Enema with air Which of the following is a family-centered care concept ? Cultural backgrounds are assessed and incorporated into the plan of care. Which of the following parameters would indicate that appropriate post resuscitation interventions were successfully carried out in the pediatric patient? Pulse oximetry reading of 96% A 5-year-old presents with decreased level of consciousness and a wide complex and rapid rate on the electrocardiogram. Which of the following characteristics would indicate ventricular tachycardia as opposed to other tachydysrhythmias? Heart rate between 120 to 200 beats/minute A child with bipolar disorder is brought to the emergency department for increasing irritability, agitation, pressured speech, and a decreased need for sleep. What should be included in the plan of care for this child? 7 | P a g e Performing a suicide risk assessment Which of the following is the priority intervention for the nurse caring for an immunocompromised pediatric patient with a fever? Placement in a negative pressure room A parent brings in a 4-month-old infant reporting seizure-like activity at home. The parent denies a fever and reports that the infant is otherwise healthy. Which of the following is most important for the nurse to inquire about? The ratio of formula to water used when mixing a bottle A 6-year-old involved in a boating crash is awaiting admission for surgical repair of a fractured ankle. Which of the following manifestations during reassessments would cause the greatest concern for possible intra-abdominal trauma? Diagnosis of intra-abdominal injury in a child can be challenging. Distracting injuries, pain, and anxiety can alter their ability to assist in pinpointing these types of injuries post-trauma. Intra-abdominal injuries can present with abdominal pain, but other important findings are shoulder pain, due to irritation of the phrenic nerve from the presence of blood or fluid in the peritoneal cavity, or umbilical or flank ecchymosis. A child with an electrical injury is seen 1 hour post event. Which of the following specimen samples would provide visual information regarding a potential complication of this injury? Electrical injuries, though they may appear to be small, can produce large amounts of damage internally, including muscle damage. Myoglobin is excreted in the urine and is evidenced by dark, red-tinged urine. A 10-year-old arrives at the ED post motor vehicle crash. The following assessment is noted: hypotension, tachycardia, absent breath sounds from the left chest with an increased respiratory rate, pain on palpation of the pelvis, tinge of blood noted at the urinary meatus, moderate active bleeding from a laceration to left thigh, pulse oximetry of 86% without supplemental oxygen, deformity to the left upper leg, and a Glasgow Coma Score of 7. Which of the following orders will prompt the nurse to have a discussion with the provider before initiating? Insert urinary catheter A child with an injury to the lower cervical spine with spinal cord involvement would most likely demonstrate which of the following findings during assessment? Decreased respiratory effort A 2-year-old arrives with parents stating the child may have ingested a button battery. The patient initially choked and coughed and is now drooling with bloody sputum. Which of the following is the priority intervention? Children who have ingested button batteries are at risk for multiple potential complications. The leaking battery fluids and electrical charge can cause ulcerations and necrosis and can lead to bleeding and airway compromise. For symptomatic patients, the child should be NPO and admitted for potential 10 | P a g e difficult to auscultate. Vitals include HR 132 beats/minute, RR 36 breaths/minute, and BP 80/55 mm Hg. Which of the following is the priority intervention? Pericardiocentesis What is the first step in the care of the newly born infant? Warm, dry, and stimulate Which of the following is the highest priority intervention for a well-appearing 2-month-old with a fever? Urine culture A child in cardiopulmonary arrest is receiving chest compressions and manual ventilations with a bag- mask device. Once return of spontaneous circulation has been confirmed, which of the following would be the priority intervention? Establishing a secure airway A 5-year-old arrives in the ED with a 4 day history of vomiting. Vital signs: HR 136 beats/minute, RR 36 breaths/minute, BP 92/56 mm Hg, T 38oC (100.4oF), and pulse oximetry 93% on room air. The child is pale with warm, dry skin and a capillary refill of 3 seconds. A fluid bolus is completed. Which of the following reassessment findings indicate that a second fluid bolus is necessary? Blood pressure of 92/78 mm Hg A 14-year-old patient presents to the emergency department with her aunt after being assaulted. The patient has multiple bruises inconsistent with the assault history and seems guarded with her answers. A urine test is positive for pregnancy, although the patient denies being sexually active. The aunt repeatedly asks when they will be discharged. The ED nurse recognizes these finding as red flags for which of the following? Sex trafficking A 17-year-old female arrives in the ED with her boyfriend who states she is pregnant and having vaginal bleeding. The patient is unsure of the gestational age and has not had any prenatal treatment. The patient is quiet and lets her boyfriend answer most of the questions. Which of the following is the most appropriate action for the nurse to take at this point? Have the boyfriend leave the room during the pelvic exam. Which of the following is the recommended method of insulin administration for a pediatric patient with diabetic ketoacidosis? Insulin infusion When taking vital signs on a stable infant, which of the following should be done first? 11 | P a g e Respiratory rate A 12-year-old female patient arrives awake and alert with an acute onset of abdominal pain on the right side, nausea, vomiting, and vaginal spotting. On palpation, the pain is localized to the right side and there is tenderness to the breasts. Which of the following laboratory tests is the priority for this patient? Human chorionic gonadotropin A 2-year-old arrives at the ED in hypovolemic shock and needs fluids immediately. After several attempts, your team has been unsuccessful at establishing vascular access. Of the following, which is the next best option for establishing access quickly? Intraosseous in the patient's medial tibia. When caring for a potential crime victim, what evidence collection principle is imperative? Clothing should not be placed on the floor in order to prevent contamination. A nurse begins making multiple errors in clinical decisions regarding the care of patients in the pediatric emergency department. The nurse has worked many consecutive shifts caring for severely ill and injured children and mentioned to a co-worker that they are not sleeping and feel anxious about coming to work. What condition may this nurse be experiencing? Vicarious traumatization or secondary traumatic stress (STS) can result from repeated exposure to traumatized or suffering patients without always knowing the outcomes. The fast-paced ED often requires the team to continue caring for patients without stopping to discuss a traumatic event. A toddler arrives in a post-ictal state. Parents describe seizure-like activity and state they gave acetaminophen earlier in the day due to fussiness. Which of the following statements by the parents would be most concerning? "He also had a seizure about 2 in the morning." A pediatric resuscitation has ended with the death of the child. Coroner notification has not been made yet. In dealing with the family of this child, how can the nurse facilitate their grieving process until legally required notification has been made? Provide simple, straightforward information A 3-week old is brought to the emergency department with a history of fussiness, spitting up, crying, and watery stools. Assessment reveals an alert child with moist mucous membranes. Which of the following should be the priority? Identify the type of feeding the caregiver uses The caregivers of a 6-year-old report the child developed a cough with nasal congestion and "pink-eye" that started two days ago. Today they noticed a raised, red rash on the face, and grey papules in the mouth. Which of the following is the priority intervention for this patient? Rubeola (measles) often presents with a high fever, cough, coryza (nasal congestion), non-purulent conjunctivitis, and Koplick spots-white or gray papules on the mucous membranes. It is a highly 12 | P a g e contagious viral illness, and patients should have standard and airborne precautions initiated immediately upon suspicion to prevent the spread. A parent presents to the emergency department carrying her 12-week-old infant. The PAT reveals an infant who is quiet and opens eyes with stimulation, whose breathing is regular and even, and whose skin is pale, with a scattered vesicular rash. What is the priority intervention for this infant? Obtain a full set of vital signs A neonate presents to the emergency department with irritability, weak cry, and hypotonia. Which of the following is a priority intervention? Serum blood glucose A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares over the past 6 hours. Which of the following foreign bodies is the most likely etiology? Button battery A term infant is delivered in the emergency department. Which assessment finding is most concerning? Central cyanosis An infant presents to the emergency department with difficulty breathing. The patient is pale and respirations appear rapid and shallow. Which location on the torso is the most effective site for assessing bilateral breath sounds? Bilateral midaxillary An anxious 12-year-old child presents to the emergency department with a sudden onset of nausea, diarrhea, abdominal cramping, flushing, and hypotension. Symptoms started about 60 minutes after lunch. Which of the following conditions is the most likely cause of these symptoms? Anaphylaxis A 13-year -old male presents to the triage desk complaining of nausea and vomiting. The patient looks distressed and pale. He complains of spasming pain in his right scrotum which has now become constant and more severe. Which of the following assessment findings would the nurse expect with this patient? Elevated right testicle A 12-year-old involved in a house fire has full thickness, circumferential burns to bilateral lower extremities. Fluid resuscitation is in progress on arrival at the ED. On assessment the left pedal and posterior tibialis pulses are absent, with delayed capillary refill. Which of the following is the priority intervention? Assist with escharotomy During the assessment of a 16-year-old patient, the ED nurse identifies them as a potential sex trafficking victim. Which of the following trauma-informed care principles has the highest priority for this patient? 15 | P a g e more than 3 seconds, and skin is pale and cool. The patient's signs and symptoms suggest: A. Obstructive shock. B. Distributive shock. C. Hypovolemic shock. D. Cardiogenic shock. C. Hypovolemic shock. A school-aged child is about to receive stitches. To evaluate his understanding of the procedure, you tell him: A. "Young people your age have questions about getting stitches. What are your questions?" B. "Don't cry while you are getting the stitches. Be brave like a man." C. "You will probably receive 10 stitches. Do you have any questions before we restrain you?" D. "Does your cut hurt? Would you like your mommy to hold you?" A. "Young people your age have questions about getting stitches. What are your questions?" What is the preferred sit for intraosseous access in the infant? A. Lateral malleolus B. Iliac crest C. Proximal femur D. Anteromedial tibia D. Anteromedial tibia An important consideration in the assessment of pain for an adolescent patient is that they: A. May deny or minimize their pain when friends visit for fear of losing control. B. Have difficulty localizing or describing the pain. C. Are unable to use the 1 to 10 scale to report their pain. D. Feel that the pain is a punishment for something they did wrong. A. May deny or minimize their pain when friends visit for fear of losing control. An 8-month-old infant with pneumonia has severe intercostal and substernal retractions, weak muscle tone, lethargy, and gray skin color. The infant's condition does not improve after bag-mask ventilation. The next step in treatment is most likely to be: A. Administration of epinephrine. B. Supplemental warming measures. C. Rapid sequence intubation. D. Administration of albuterol. C. Rapid sequence intubation. Which combination of medications is best to have prepared for a pediatric resuscitation? A. Dopamine and sodium bicarbonate. B. Epinephrine and glucose. C. Naloxone and lidocaine. D. Pentothal and vecuronium. 16 | P a g e B. Epinephrine and glucose. A 20-day-old infant has a 1-week history of not eating well. The infant has a weak cry and is jittery. Which laboratory test is indicated? A. Arterial blood gas. B. Finger-stick glucose. C. Complete blood count with differential. D. Toxicology screen. B. Finger-stick glucose. Which intervention should be performed next if tactile stimulation, positioning, drying, and blow-by oxygen administration do not increase a newborn's heart rate? A. Chest compressions. B. Umbilical vein cannulation. C. Endotracheal intubation. D. Bag-mask ventilation. D. Bag-mask ventilation. A 10-kg child has deep partial-thickness burns over 35% of the total body surface area. Which evaluation parameter indicates that fluid resuscitation is adequate? A. Heart rate of 160 beats/minute. B. Respiratory rate of 34 breaths/minute. C. Blood pressure of 80/60 mm Hg. D. Urine output of 11 ml/hour. D. Urine output of 11 ml/hour. A 7-year-old female sustains a minor head injury and did not lose consciousness. She does not respond to commands and groans in response to questions. Which action will quickly determine if her behavior indicates a serious head injury? A. Review her medical record for pre-existing developmental problems. B. Obtain a head computerized tomography scan. C. Conduct a developmental screening test. D. Ask the parents if her behavior is unusual. D. Ask the parents if her behavior is unusual. An 8-month-old child presents with purpura, irritability, and a rectal temperature of 39.4�C (102.9�F). An intervention of high priority is: A. Encouraging the caregiver to hold and comfort the child. B. Monitoring for signs and symptoms of increased intracranial pressure (ICP). C. Collecting urine for toxicology screen. D. Encouraging oral fluids and food. B. Monitoring for signs and symptoms of increased intracranial pressure (ICP). 17 | P a g e The Pediatric Assessment Triangle is used to: A. Identify all life-threatening conditions that the child presents with. B. Perform a complete head-to-toe assessment on the child. C. Assess the status of the child's airway only upon arrive in the ED. D. Determine the severity of the child's illness or injury using the "across-the-room" assessment. D. Determine the severity of the child's illness or injury using the "across-the-room" assessment. The caregivers of a 6-year-old boy who is brought to the emergency department for abdominal pain should first be asked: A. "Are his immunizations current?" B. "Has anything happened to him at school recently?" C. "What is the reason for the child's visit and how long has he been ill?" D. "Has he been complaining of a sore throat or earache?" C. "What is the reason for the child's visit and how long has he been ill?" A 9-month-old infant is crying loudly through the nursing assessment, and the caregiver is becoming distraught. The nurse should ask the caregiver to: A. Read a story to the infant. B. Offer the infant a pacifier. C. Return when the infant is consoled. D. Ignore the infant's behavior. B. Offer the infant a pacifier. During an intubation attempt, the child�s heart rate drops to 40 beats/minute. Which intervention is indicated? A. Ask the physician to stop the intubation attempt and perform bag-mask ventilation. B. Apply cricoid pressure and establish intravenous access. C. Inform the physician of the heart rate and ask the physician to intubate faster. D. Administer blow-by oxygen and begin chest compressions. A. Ask the physician to stop the intubation attempt and perform bag-mask ventilation. A 6- week-old infant is pale, has marked substernal retractions, expiratory grunting, and poor muscle tone. The emergency nurse should first: A. Obtain intravenous access. B. Apply a pulse oximeter. C. Prepare a chest x-ray. D. Administer 100% oxygen. D. Administer 100% oxygen. The best method to open the airway in an injured child is: A. Placing the head and neck in hyperextension. B. Using the jaw thrust maneuver. C. Placing the head and neck in flexion. D. Using the head tilt maneuver. 20 | P a g e Which of the following is the highest priority intervention for a well-appearing 2-month-old with a fever? A. Lumbar puncture B. Urine culture C. Intravenous fluid bolus D. Chest radiograph B. Urine culture The caregivers of a 6-year-old report the child developed a cough with nasal congestion and "pink-eye" that started two days ago. Today they noticed a raised, red rash on the face, and grey papules in the mouth. Which of the following is the priority intervention for this patient? A. Obtain a nasopharyngeal swab B. Place in airborne isolation C. Place in contact isolation D. Obtain a fingerstick glucose C. Place in contact isolation A 14-year-old patient with Down syndrome presents with an abnormal gait, head tilted to the left, decreased sensation to the extremities, and urinary incontinence. The patient has no history of trauma. Which of the following diagnostics is the priority for this patient? A. Lumbar spine magnetic resonance imaging B. Complete neurologic exam C. Urinalysis by straight catheterization D. Cervical spine radiographs D. Cervical spine radiographs A 7-year-old is being seen for new onset of headaches. Which of the following manifestations would most likely rule out the potential of a primary etiology? A. Presence of ataxia B. Pulsating, unilateral pain C. Occurrence of photophobia D. Nausea, vomiting A. Presence of ataxia A 3-week old is brought to the emergency department with a history of fussiness, spitting up, crying, and watery stools. Assessment reveals an alert child with moist mucous membranes. Which of the following should be the priority? A. Medicate with ondansetron for emesis B. Identify the type of formula the caregiver uses C. Obtain a stool specimen for culture D. Initiate intravenous access with 0.9% sodium chloride 21 | P a g e B. Identify the type of formula the caregiver uses A laceration on a toddler's arm is prepared for suturing. Which of the following preparations for topical anesthesia would be the best choice for this procedure? A. EMLA (lidocaine 2.5% and prilocaine 2.5%) B. LET (lidocaine/epinephrine/tetracaine) C. LMX (lidocaine 4%) D. Tetracaine 4% B. LET (lidocaine/epinephrine/tetracaine) A 6-month-old arrives with swelling to the left thigh. Caregivers deny any traumatic event. Assessment findings include a patient who is active and alert, in the 10th percentile for length, and has blue-grey sclera. Radiographs reveal a midshaft fracture of the left femur. Which of the following is the most likely cause? A. Osteomyelitis B. Physical maltreatment C. Ehlers-Danlos syndrome D. Osteogenesis imperfecta D. Osteogenesis imperfecta A 3 year-old patient presents following frequent emesis and diarrhea over the past 12 hours. Which of the following assessment findings indicate that the patient' body is compensating for the fluid loss? A. Increased diastolic blood pressure B. Bounding peripheral pulses C. Prolonged capillary refill D. Increased urine output A. Increased diastolic blood pressure A 6-year-old involved in a boating crash is awaiting admission for surgical repair of a fractured ankle. Which of the following manifestations during reassessments would cause the greatest concern for possible intra-abdominal trauma? A. Chest pain with deep inspiration B. Thoracic spine pain with palpation C. Intermittent shortness of breath D. Constant left shoulder pain D. Constant left shoulder pain During the assessment of a 16-year-old patient, the ED nurse identifies them as a potential sex trafficking victim. Which of the following trauma-informed care principles has the highest priority for this patient? A. Empowerment, voice, and choice B. Peer support 22 | P a g e C. Trustworthiness and transparency D. Physical and psychological safety D. Physical and psychological safety. A 6-year-old involved in a boating crash is awaiting admission for surgical repair of a fractured ankle. Which of the following manifestations during reassessments would cause the greatest concern for possible intra-abdominal trauma? A. Chest pain with deep inspiration B. Thoracic spine pain with palpation C. Intermittent shortness of breath D. Constant left shoulder pain D. Constant left shoulder pain A caregiver reports their one-month-old has had a yellowish color to their eyes and skin over the last two weeks. If left untreated, which body system can this affect? A. Integumentary B. Renal C. Gastrointestinal D. Neurological A. Integumentary A neonate presents to the emergency department with irritability, weak cry, and hypotonia. Which of the following is a priority intervention? A. Prostaglandin infusion B. Toxin screening C. Head compterized tomography scan D. Serum blood glucose D. Serum blood glucose An 8-year-old arrives post bicycle crash with swelling and bleeding from the right side of his face, deformities to the jawline, nasal swelling, and epistaxis. He is unresponsive with snoring respirations and an absent gag reflex. Which of the following airway adjuncts would be most appropriate for this patient? A. Nasopharyngeal airway (NPA) B. Head tilt - chin lift maneuver C. Elevate the head of the bed D. Oropharyngeal airway (OPA) D. Oropharyngeal airway (OPA) A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares over the past 6 hours. Which of the following foreign bodies is the most likely etiology? A. Magnet 25 | P a g e B. Administer 5 -10 ml of honey orally C. Discharge with specific return instructions D. Offer the child sips of water intermittently A. Prepare the patient for hospitalization When caring for a potential crime victim, what evidence collection principle is imperative? A. Evidence collection is prioritized over nursing assessment. B. Suspicious clothing should be placed in separate, clean, clearly marked plastic bags. C. Clothing should always be cut along seam lines to preserve evidence. D. Clothing should not be placed on the floor in order to prevent contamination. D. Clothing should not be placed on the floor in order to prevent contamination. A child with an electrical injury is seen 1 hour post event. Which of the following types of specimen samples would provide visual information regarding a potential complication of this injury? A. Serum B. Urine C. Stool D. Sputum B. Urine A 2-year-old arrives at the ED in hypovolemic shock and needs fluids immediately. After several attempts, your team has been unsuccessful at establishing vascular access. Of the following, which is the next best option for establishing access quickly? A. Intraosseous in the patient's medial tibia. B. Peripherally inserted central catheter C. Assisting with central line placement. D. Intraosseous in the patient's scapula. A. Intraosseous in the patient's medial tibia. A child has a nondisplaced fracture of the radius that has been splinted, with a sling in place and NSAIDs given for pain. Prior to discharge home with follow-up at a pediatric facility, what actions must be completed? A. Discharge instructions including follow-up contact information. B. Ensure the receiving facility has space and qualified personnel. C. Certify that medical benefits of discharge outweigh risks. D. Complete doctor-to-doctor communication with receiving facility. A. Discharge instructions including follow-up contact information. The nurse is triaging an infant brought to the emergency department by their caregiver. Which finding by the nurse leads the infant to be placed in isolation? A. Barking cough B. Purpuric rash C. High-pitched cry D. Mottled skin 26 | P a g e B. Purpuric rash Parents with an infant requiring multiple laboratory tests, radiographic studies, and invasive procedures appear to be distressed and withdrawn. Which of the following interventions would best ensure a sense of comfort and control for these parents? A. Taking the child to the radiographic studies while the parents rest in the room B. Providing frequent updates and re-educating them on the care that is being provided C. Ensuring adequate lighting and keeping the door closed to provide privacy D. Answering questions only when the parents ask them in order to reduce information overload B. Providing frequent updates and re-educating them on the care that is being provided An infant presents to the emergency department with difficulty breathing. The patient is pale and respirations appear rapid and shallow. Which location on the torso is the most effective site for assessing bilateral breath sounds? A. Bilateral posterior back B. Over the epigastrium C. Bilateral midaxillary D. Bilateral anterior chest C. Bilateral midaxillary A child was found unresponsive under the monkey bars during recess and arrives with the following assessment: eyes open only with supraorbital pressure stimulus, no verbal response is elicited, and withdraws arms and legs when a swab is inserted in the nose. Which of the following is the priority intervention for this child? A. Infuse a bolus of crystalloid solution B. Expose the child's body for full exam C. Log roll to assess posterior aspect D. Prepare for immediate intubation D. Prepare for immediate intubation A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after eating lunch. Which of the following is the priority intervention? A. Intramuscular epinephrine B. Inhaled albuterol C. Oral diphenhydramine D. Intravenous ondansetron A. Intramuscular epinephrine A 12-year-old is being prepped for surgical intervention of acute appendicitis. Which of the following intravenous medication orders should the nurse question? A. Morphine B. Acetaminophen C. Hydromorphone D. Ketorolac 27 | P a g e D. Ketorolac An 18-month-old is seen for fever, slight circumoral cyanosis, and wheezing noted on auscultation in the right upper lobe of the lung field after a choking event 4 days ago. The white blood cell count is elevated and the patient noted to be tachypneic, tachycardic, agitated, and has an increased respiratory effort. At the time of the event, the patient was started on antibiotics with subsequent increasing manifestations instead of improvement. Which of the following would be considered to be definitive treatment for the suspected diagnosis? A. Computed tomography B. Magnetic resonance imaging C. Bronchoscopy D. Ultrasound C. Bronchoscopy Parents report their 3-year-old child has developed noisy breathing. On assessment, high-pitched wheezes are audible and auscultated on inspiration and expiration. What medication would be appropriate to administer first? A. Humidified oxygen B. Inhaled beta-agonist C. Oral steroids D. Nebulized magnesium sulfate B. Inhaled beta-agonist A 3-year-old child who was found in a pool unresponsive has return of spontaneous circulation (ROSC) after prolonged resuscitation. Intubation was performed in the field. Upon arrival to the ED, which intervention is of highest priority? A. Administer sedation as ordered. B. Utilize a length-based resuscitation tape to determine the approximate weight. C. Auscultate breath sounds over the epigastrium and lung fields. D. Obtain a bedside blood glucose reading. C. Auscultate breath sounds over the epigastrium and lung fields. A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares over the past 6 hours. Which of the following foreign bodies is the most likely etiology? A. Magnet B. Button battery C. Dried bean D. Fishing weight 30 | P a g e When taking vital signs on a stable infant, which of the following should be done first? Respiratory rate A laceration on a toddler's arm is prepared for suturing. Which of the following preparations for topical anesthesia would be the best choice for this procedure? LET (lidocaine/epinephrine/tetracaine) Which of the following is appropriate administration of N-acetylcysteine (NAC) for an acetaminophen overdose? A bolus infusion of 150 mg/kg NAC should be administered. A 10-year-old arrives at the ED post motor vehicle crash. The following assessment is noted: hypotension, tachycardia, absent breath sounds from the left chest with an increased respiratory rate, pain on palpation of the pelvis, tinge of blood noted at the urinary meatus, moderate active bleeding from a laceration to left thigh, pulse oximetry of 86% without supplemental oxygen, deformity to the left upper leg, and a Glasgow Coma Score of 7. Which of the following orders will prompt the nurse to have a discussion with the provider before initiating? Assist with chest tube insertion (wrong) Remediation feedback: Urinary catheters are contraindicated for placement if pelvic injury is suspected or blood is noted at the urinary meatus. Scrotal or perineal discolorations with edema to the areas is also a contraindication for this adjunct. A 2-year-old is seen with a 3-day history of irritability, vomiting, and the presence of foul-smelling urine. The child is hypotensive and tachycardic. Which of the following methods for obtaining a urine sample is most appropriate in this circumstance? Urinary catherization A child with bipolar disorder is brought to the emergency department for increasing irritability, agitation, pressured speech, and a decreased need for sleep. What should be included in the plan of care for this child? Performing a suicide risk assessment You are discharging a patient home who has a history of depression. Discharge teaching should include which of the following? Ensuring all firearms in the home are locked up with no access available by the patient. A 5-year-old child presents with hives, swelling of the lips and face, and stridor that developed about an hour after eating lunch. The child has no known allergies. Which of the following is the priority intervention? Administer intramuscular epinephrine 31 | P a g e Which of the following pathologic processes would most likely be attributed to a primary diagnosis of cystic fibrosis? Constipation A 2-year-old arrives with a 2-day history of vomiting and diarrhea. The patient has a fever of 38.4oC (101.2°F), resting HR of 152 beats/minute, RR of 34 breaths/minute, and blood pressure of 94/ 56 mm Hg. Assessment reveals a capillary refill time of > 5 seconds. Which of the following would be most indicative of the need for intravenous rehydration therapy for this patient? Capillary refill Which of the following is a family-centered care concept ? Cultural backgrounds are assessed and incorporated into the plan of care. An 8-month-old arrives with a 12-hour history of intermittent abdominal pain, non-bilious vomiting, and a low grade fever. On assessment the child is intermittently inconsolable followed by periods of normal activity. A sausage-shaped mass is noted during palpation of the abdomen. The nurse should prepare for which of the following? Enema with air A caregiver presents to the emergency department with an 18-month-old and reports the child is not using their left arm after playing a game with an older sibling. The child is alert and curious, with regular, even respirations, and skin color is appropriate. Using the Pediatric Assessment Triangle (PAT), how would you categorize this patient? Sick A 13-year -old male presents to the triage desk complaining of nausea and vomiting. The patient looks distressed and pale. He complains of spasming pain in his right scrotum which has now become constant and more severe. Which of the following assessment findings would the nurse expect with this patient? Elevated right testicle An 8-year-old trauma patient suddenly develops increased respiratory distress with a rise in heart rate from 112 beats/minute to 142 beats/minute associated with an abrupt hypotensive event. Distention of the jugular veins is noted. Which of the following emergent interventions should be anticipated first? Drug assisted intubation (wrong) Remediation feedback: Tension pneumothorax is a complication of trauma associated with an original pneumothorax. Air in the pleural space increases and compresses the heart and great vessels creating a type of obstructive shock. A hallmark sign, tracheal deviation, can be difficult to see in the pediatric patient. Needle decompression is emergently necessary to release the air and allow expansion of the lung again. An 8-year-old pedestrian is thrown onto the hood of a moving vehicle striking the windshield. On arrival to the ED. the patient is minimally responsive with active bleeding from the nose and mouth. The patient is vomiting. Which of the following interventions would most likely be considered? 32 | P a g e Endotracheal intubation The nurse is reevaluating the effectiveness of interventions for a 4-year-old child with a suspected tension pneumothorax. Which assessment finding indicates the interventions were effective? Bilateral chest wall rise with assisted ventilations. A 3-year-old is brought by caregivers with generalized tonic-clonic activity, unresponsiveness, and drooling that began 6 minutes prior to arrival. Which of the following interventions would be most appropriate for this event? Administer intranasal midazolam A 6-month-old arrives with swelling to the left thigh. Caregivers deny any traumatic event. Assessment findings include a patient who is active and alert, in the 10th percentile for length, and has blue-grey sclera. Radiographs reveal a midshaft fracture of the left femur. Which of the following is the most likely cause? Ehlers-Danlos syndrome (wrong) Remediation feedback: Osteogenesis imperfecta is a genetic disorder that includes short stature, blue-grey color to the sclera, discolored teeth, and laxity of the ligaments. Such patients are susceptible to fractures, especially of the midshaft of long bones. These patients are often mistaken for victims of child maltreatment. A 14-year-old patient had a reduction of a temporomandibular joint dislocation in the ED. Which of the following should be included in the discharge instructions? Practice yawning three to four times a day (wrong) Remediation feedback: Patients with temporomandibular joint dislocation should avoid activities that involve extreme jaw joint opening. Cold or warm, not hot, compresses are recommended along with nonsteroidal anti- inflammatory medications for pain control. A 5-year-old patient presents with severe dehydration and signs of shock due to viral gastroenteritis. Which of the following physiologic responses by this patient will have the greatest impact on improving their cardiac output? Increased heart rate An 8-year-old male presents to the emergency department with incoherent speech, hallucinations, and violent behavior. What is the priority in caring for this patient? Ensure safety of the patient and staff A 12-year-old presents to the emergency department with a severe headache. The mother reports that the child has been experiencing headaches and has had multiple seizures for the past several months. The child was seen by their primary doctor and prescribed an anti-seizure medication, but the 35 | P a g e Temperature 37.7°C (99.9°F) During a diaper change on a 4-month-old infant, the nurse measures the infant's urinary output. After subtracting the weight of a dry diaper, the wet diaper weighs 22 grams. What is the infant's estimated urinary output? 22 mL A 3 year-old patient presents following frequent emesis and diarrhea over the past 12 hours. Which of the following assessment findings indicate that the patient' body is compensating for the fluid loss? Prolonged capillary refill (wrong) Remediation feedback: In the early compensated phase of shock attributed to fluid volume loss, the diastolic pressure will increase due to vasoconstriction (increasing systemic vascular resistance) as a compensatory mechanism causing a narrowed pulse pressure. A normal systolic pressure is maintained during this phase. Other manifestations of early shock states are tachycardia, normal capillary refill, decreased urine output, mild irritability, tachypnea, and weak peripheral pulses. A neonate presents to the emergency department with irritability, weak cry, and hypotonia. Which of the following is a priority intervention? Serum blood glucose Head compterized tomography scan Prostaglandin infusion Toxin Screening Which of the following pathologic processes would most likely be attributed to a primary diagnosis of cystic fibrosis? Hypernatremia *Constipation Obesity Epiglottitis A nurse begins making multiple errors in clinical decisions regarding the care of patients in the pediatric emergency department. The nurse has worked many consecutive shifts caring for severely ill and injured 36 | P a g e children and mentioned to a co-worker that they are not sleeping and feel anxious about coming to work. What condition may this nurse be experiencing? Nurse traumatization Pediatric Traumatization Direct Traumatization *Vicarious Traumatization A 14-year-old patient with Down syndrome presents with an abnormal gait, head tilted to the left, decreased sensation to the extremities, and urinary incontinence. The patient has no history of trauma. Which of the following diagnostics is the priority for this patient? Lumbar Spine MRI Complete Neurologic Exam Urinalysis by Straight Catheter *Cervical Spine Radiograph The caregivers of a 6-year-old report the child developed a cough with nasal congestion and "pink-eye" that started two days ago. Today they noticed a raised, red rash on the face, and grey papules in the mouth. Which of the following is the priority intervention for this patient? Obtain a nasopharyngeal swab *Airborne Isolation Contact Isolation Fingerstick Glucose A 12-year-old is being prepped for surgical intervention of acute appendicitis. Which of the following intravenous medication orders should the nurse question? Morphine Acetaminophen Hydromorphone *Ketorolac A child with an injury to the lower cervical spine with spinal cord involvment would most likely demonstrate which of the following findings during assessment? 37 | P a g e Increased rectal tone Increased urinary outcomes Decreased end-tidal CO2 *Decreased Respiratory effort An adolescent is awaiting ICU admission for pneumonia. During reassessment, which of the following findings would be most indicative that respiratory failure is developing? SpO2 of 94 % on room air Widened Pulse Pressure *Extreme Lethargy Flash Capillary Refill A pediatric resuscitation has ended with the death of the child. Coroner notification has not been made yet. In dealing with the family of this child, how can the nurse facilitate their grieving process until legally required notification has been made? Defer all questions to the provider Allow family member to hold the pt *Provide simple, Straight forward information Begin Memory making activities Parents with an infant requiring multiple laboratory tests, radiographic studies, and invasive procedures appear to be distressed and withdrawn. Which of the following interventions would best ensure a sense of comfort and control for these parents? *Providing frequent updates and re-educating them on the care that is being provided Taking the child to the radiographic studies while the parents rest in the room Ensuring adequate lighting and keeping the door closed to provide privacy Answering questions only when the parents ask them in order to reduce information overload Return of spontaneous circulation has been confirmed in a 5-year-old following cardiopulmonary arrest after a 5-day history of vomiting and diarrhea. Vital signs are BP 72/60 mm Hg, HR 140 beats/minute, RR assisted at 30 breaths/minute via definitive airway, SpO2 97%, and T 36.8°C (98.4°F) rectally. Which of the following would be the priority intervention at this time? 40 | P a g e Respiratory Rate of 26 BPM Which of the following is the highest priority intervention for a well-appearing 2-month-old with a fever? Lumbar Puncture Urine Culture Intravenous Fluid Bolus Chest XR A 3-week old is brought to the emergency department with a history of fussiness, spitting up, crying, and watery stools.Assessment reveals an alert child with moist mucous membranes. Which of the following should be the priority? Identify the type of Formula Stool Sample Medicate with zofran intitiane iv access A 6-week-old is brought to the emergency department by the caregivers for poor feeding, listlessness, and fever. Assessment reveals a crying infant, HR 160 beats/minute, RR 52 breaths/minute, rectal temperature of 96.0 F (35.5 C), and a bulging anterior fontanel. Capillary refill is 4 seconds. Based on these findings what is the most likely diagnostic test the nurse should anticipate? B.Lumbar puncture A 2-year-old arrives at the ED in hypovolemic shock and needs fluids immediately. After several attempts, your team has been unsuccessful at establishing vascular access. Of the following, which is the next best option for establishing access quickly? Intraosseous in the patient's medial tibia. A 13-year-old is experiencing a sudden onset of testicular pain, swelling, and vomiting. The cremasteric reflex is absent. Which of the following diagnoses is of highest suspicion in this situation? Testicular Torsion After an explosion at a school, you are helping triage patients. In your field triage room you find a 5- year-old patient who is not breathing. What is the appropriate initial intervention? 41 | P a g e Open the Airway and assess for breathing A parent presents to the emergency department carrying her 12-week-old infant. The PAT reveals an infant who is quiet and opens eyes with stimulation, whose breathing is regular and even, and whose skin is pale, with a scattered vesicular rash. What is the priority intervention for this infant? Initiate isolation precautions A 12-year-old complains of a severe headache for the past 8 hours. Which of the following past history disease processes would be considered a "red flag" and warrant immediate evaluation for this patient? Sickle Cell A 14-year-old patient presents to the emergency department with her aunt after being assaulted. The patient has multiple bruises inconsistent with the assault history and seems guarded with her answers. A urine test is positive for pregnancy, although the patient denies being sexually active. The aunt repeatedly asks when they will be discharged. The ED nurse recognizes these finding as red flags for which of the following? Sex Trafficking A 12-year-old presents to the emergency department with a severe headache. The mother reports that the child has been experiencing headaches and has had multiple seizures for the past several months. The child was seen by their primary doctor and prescribed an anti-seizure medication, but the prescription was not filled because "the doctor just wants money." This is an example of what type of neglect? Medical Which of the following is the recommended method of insulin administration for a pediatric patient with diabetic ketoacidosis? Insulin Infusion Which of the following is the priority intervention for the nurse caring for an immunocompromised pediatric patient with a fever Negative Pressure Room An anxious 12-year-old child presents to the emergency department with a sudden onset of nausea, diarrhea, abdominal cramping, flushing, and hypotension. Symptoms started about 60 minutes after lunch. Which of the following conditions is the most likely cause of these symptoms? Anaphylaxis A school-aged child arrives in the emergency department with a 2-day history of vomiting. The child is cool and pale, with weak pulses, elevated heart rate, and capillary refill of 4 to 5 seconds. Which of the following is the priority intervention for the child? Fluids 42 | P a g e A child in cardiopulmonary arrest is receiving chest compressions and manual ventilations with a bag- mask device. Once return of spontaneous circulation has been confirmed, which of the following would be the priority intervention? Establishing Airway An 8-year-old pedestrian is thrown onto the hood of a moving vehicle striking the windshield. On arrival to the ED. the patient is minimally responsive with active bleeding from the nose and mouth. The patient is vomiting. Which of the following interventions would most likely be considered? Intubation Which of the following parameters would indicate that appropriate post resuscitation interventions were successfully carried out in the pediatric patient? Pulse Ox 96% A 12-year-old involved in a house fire has full thickness, circumferential burns to bilateral lower extremities. Fluid resuscitation is in progress on arrival at the ED. On assessment the left pedal and posterior tibialis pulses are absent, with delayed capillary refill. Which of the following is the priority intervention? Elevate A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after eating lunch. Which of the following is the priority intervention? IM Epi An 8-year-old male presents to the emergency department with incoherent speech, hallucinations, and violent behavior. What is the priority in caring for this patient? Ensure safety A 3-year-old has a two-day history of runny nose, low-grade fever, and a "barky" cough at night. The child is awake and alert with noted stridor. Pulse oximetry is 96% on room air. Which of the following interventions would be the most appropriated for this child? Neb Epi A child with an electrical injury is seen 1 hour post event. Which of the following specimen samples would provide visual information regarding a potential complication of this injury? Urine Which of the following is appropriate administration of N-acetylcysteine (NAC) for an acetaminophen overdose? Bolus 150mg/kg 45 | P a g e C.Gastrointestinal D.Neurological An infant presents to the emergency department with difficulty breathing. The patient is pale and respirations appear rapid and shallow. Which location on the torso is the most effective site for assessing bilateral breath sounds? A.Bilateral posterior back B.Over the epigastrium C.Bilateral midaxillary D.Bilateral anterior chest A 5-year-old presents with sudden onset nausea, vomiting, abdominal cramping, hives, and hypotension after eating lunch. Which of the following is the priority intervention? A.Intramuscular epinephrine B.Inhaled albuterol C.Oral diphenhydramine D.Intravenous ondansetron A 3-year-old is assessed for the presence of increasing amounts of serosanguineous drainage from his left nares over the past 6 hours. Which of the following foreign bodies is the most likely etiology? A.Magnet B.Button battery C.Dried bean D.Fishing weight Caregivers state an 18-month-old child had a harsh, barky cough, low-grade fever, and irritability throughout the night. On assessment this morning, the child appears alert, is interactive, their present cough is quiet, and their temperature is 98.8°F (37.1°C) axillary. Which of the following diagnoses is the highest probablity for this child? A.Asthma B.Croup C.Epiglottitis D.Pneumonia A 12-year-old female patient arrives awake and alert with an acute onset of abdominal pain on the right side, nausea, vomiting, and vaginal spotting. On palpation, the pain is localized to the right side and there is tenderness to the breasts. Which of the following laboratory tests is the priority for this patient? A.Human chorionic gonadotropin B.Complete blood count C.Vaginal cultures D.Bedside glucose level 46 | P a g e A fertilizer silo exploded during a school tour of a working farm. The children are able to manage their own secretions but all are incontinent and salivating, with excess tearing. Which of the following is the priority intervention? A.Removal of clothing and decontamination B.Establishing patient identification C.Rapid administration of atropine D.Providing supportive treatment A caregiver states their 3-year-old child ate some marijuana gummies approximately 3 hours prior to arrival. The PAT reveals the child is pink, difficult to arouse, and work of breathing is normal. What is your initial intervention? A.Administer activated charcoal B.Check the child's blood glucose C.Initiate intravenous access D.Obtain a full set of vital signs A 14-year-old patient presents to the emergency department with her aunt after being assaulted. The patient has multiple bruises inconsistent with the assault history and seems guarded with her answers. A urine test is positive for pregnancy, although the patient denies being sexually active. The aunt repeatedly asks when they will be discharged. The ED nurse recognizes these finding as red flags for which of the following? A.Labor trafficking B.Sex trafficking C.Psychological abuse D.Physical abuse A 12-year-old restrained, back -seat passenger involved in a motor vehicle crash is noted to have hypotension, tachycardia, and contusions and discoloration across the lap area. On exam a splenic rupture is suspected. Which of the following diagnoses should be suspected as a companion injury with these findings and associated mechanism of injury? A.Lumbar fracture B.Pneumothorax C.Subdural hematoma D.Cardiac tamponade Which patient reflects an EMTALA compliant transfer? A.An actively seizing toddler being transferred to a pediatric-specific facility. That facility is checking on inpatient bed availability. B.A post-ictal patient with status epilepticus being transferred to a higher level of care with an accepting physician. All records are copied. C.A teenager with abdominal trauma and critical labs being transferred to a pediatric trauma center for surgery. The facility has not accepted the transfer yet. 47 | P a g e D.An infant with respiratory difficulties being transferred to another hospital with the same level of pediatric care. Parents are not present, and records are copied. After an explosion at a school, you are helping triage patients. In your field triage room you find a 5- year-old patient who is not breathing. What is the appropriate initial intervention? A.Assign the patient as black/expectant. B.Open the airway and assess for breathing. - - C.Check for capillary refill of < 2 seconds D.Initiate cardiopulmonary resuscitation Return of spontaneous circulation has been confirmed in a 5-year-old following cardiopulmonary arrest after a 5-day history of vomiting and diarrhea. Vital signs are BP 72/60 mm Hg, HR 140 beats/minute, RR assisted at 30 breaths/minute via definitive airway, SpO2 97%, and T 36.8°C (98.4°F) rectally. Which of the following would be the priority intervention at this time? A.Obtain a 12-lead electrocardiogram B.Administer maintenance fluids C.Obtain a chest radiograph D.Administer an isotonic crystalloid bolus A child in cardiopulmonary arrest is receiving chest compressions and manual ventilations with a bag- mask device. Once return of spontaneous circulation has been confirmed, which of the following would be the priority intervention? A.Initiating targeted temperature management B.Performing a capillary glucose level C.Establishing a secure airway D.Administering maintenance IV fluids A child with bipolar disorder is brought to the emergency department for increasing irritability, agitation, pressured speech, and a decreased need for sleep. What should be included in the plan of care for this child? A.Limiting caregiver presence in the room B.Providing distraction using loud video games C.Performing a suicide risk assessment D.Allowing unrestricted movement throughout the department. A 5-year-old patient presents with severe dehydration and signs of shock due to viral gastroenteritis. Which of the following physiologic responses by this patient will have the greatest impact on improving their cardiac output? A.Increased heart rate B.Decreased preload 50 | P a g e An 8-year-old trauma patient suddenly develops increased respiratory distress with a rise in heart rate from 112 beats/minute to 142 beats/minute associated with an abrupt hypotensive event. Distention of the jugular veins is noted. Which of the following emergent interventions should be anticipated first? A.High-flow oxygen B.Drug-assisted intubation C.Surgical thoracotomy D.Needle decompression A child was found unresponsive under the monkey bars during recess and arrives with the following assessment: eyes open only with supraorbital pressure stimulus, no verbal response is elicited, and withdraws arms and legs when a swab is inserted in the nose. Which of the following is the priority intervention for this child? A.Infuse a bolus of crystalloid solution B.Expose the child's body for full exam C.Log roll to assess posterior aspect D.Prepare for immediate intubation A parent brings in a 4-month-old infant reporting seizure-like activity at home. The parent denies a fever and reports that the infant is otherwise healthy. Which of the following is most important for the nurse to inquire about? A.The likelihood of the infant ingesting a harmful substance B.The temperature of the bath water when bathing the infant C.The method by which the parent is measuring the temperature D.The ratio of formula to water used when mixing a bottle During a diaper change on a 4-month-old infant, the nurse measures the infant's urinary output. After subtracting the weight of a dry diaper, the wet diaper weighs 22 grams. What is the infant's estimated urinary output? A.33 mL B.11 mL C.44 mL D.22 mL An 8-year-old arrives following a bicycle crash with swelling and bleeding from the right side of his face, deformities to the jawline, nasal swelling, and epistaxis. He is unresponsive with snoring respirations and an absent gag reflex. Which of the following airway adjuncts would be most appropriate for this patient? A.Nasopharyngeal airway (NPA) B.Head tilt - chin lift maneuver C.Elevate the head of the bed D.Oropharyngeal airway (OPA) 51 | P a g e A 5-year-old arrives in the ED with a 4 day history of vomiting. Vital signs: HR 136 beats/minute, RR 36 breaths/minute, BP 92/56 mm Hg, T 38oC (100.4oF), and pulse oximetry 93% on room air. The child is pale with warm, dry skin and a capillary refill of 3 seconds. A fluid bolus is completed. Which of the following reassessment findings indicate that a second fluid bolus is necessary? A.Blood pressure of 92/78 mm Hg B.Heart rate of 114 beats per minute C.Capillary refill of 2 seconds D.Respiratory rate of 26 breaths per minute A term infant is delivered in the emergency department. Which assessment finding is most concerning? A.Acrocyanosis B.Respiratory rate 50 breaths/ minute C.Central cyanosis D.Heart rate 150 beats/minute A teenager presents to the ED for evaluation of pain with deep inspiration. The pain was a sudden onset after running track at school. While obtaining the history, the patient states that they have Marfan Syndrome. What would be a priority triage question based on this information? A."Are you current on your immunizations?" B."Have you ever had a pneumothorax?" C."Have you recently taken any recreational or illegal drugs?" D."Do you have a history of asthma?" A 5-year-old child presents with hives, swelling of the lips and face, and stridor that developed about an hour after eating lunch. The child has no known allergies. Which of the following is the priority intervention? A.Administer intramuscular epinephrine B.Auscultate bilateral breath sounds C.Insert an intravenous catheter D.Administer inhaled albuterol An adolescent is awaiting ICU admission for pneumonia. During reassessment, which of the following findings would be most indicative that respiratory failure is developing? A.SpO2 of 94 % on room air B.Widened pulse pressure C.Extreme lethargy D.Flash capillary refill An 8-year-old male presents to the emergency department with incoherent speech, hallucinations, and violent behavior. What is the priority in caring for this patient? A.Administer antipsychotic medications B.Evaluate laboratory values 52 | P a g e C.Allow family and friend visitation D.Ensure safety of the patient and staff A 14-year-old patient had a reduction of a temporomandibular joint dislocation in the ED. Which of the following should be included in the discharge instructions? A.Practice yawning three to four times a day B.Resume eating a regular diet later today C.Apply hot packs to the joint area for pain control D.Use a nonsteroidal anti-inflammatory for pain control A 3-year-old has a two-day history of runny nose, low-grade fever, and a "barky" cough at night. The child is awake and alert with noted stridor. Assessment reveals moderate retractions. Pulse oximetry is 96% on room air. Which of the following interventions would be the most appropriate for this child? A.Delivery of humidified oxygen by nasal cannula B.Administration of nebulized epinephrine C.Suctioning secretions from the oropharynx D.Administration of albuterol with a spacer A 14-year-old patient with Down syndrome presents with an abnormal gait, head tilted to the left, decreased sensation to the extremities, and urinary incontinence. The patient has no history of trauma. Which of the following diagnostics is the priority for this patient? A.Lumbar spine magnetic resonance imaging B.Complete neurologic exam C.Urinalysis by straight catheterization D.Cervical spine radiographs A 13-year -old male presents to the triage desk complaining of nausea and vomiting. The patient looks distressed and pale. He complains of spasming pain in his right scrotum which has now become constant and more severe. Which of the following assessment findings would the nurse expect with this patient? A.Foul smelling penile discharge B.Persistent penile erection C.Elevated right testicle D.Hematuria and pyuria Parents report their 3-year-old child has developed noisy breathing. On assessment, high-pitched wheezes are audible and auscultated on inspiration and expiration. What medication would be appropriate to administer first? A.Humidified oxygen B.Inhaled beta-agonist C.Oral steroids D.Nebulized magnesium sulfate