Answer and Rationale: Board Exam Nursing Test II NLE


1. C. Nothing must be placed in the mouth of a toddler who just undergone a cleft palate repair until the suture line has completely healed. It is the nurse’s responsibility to inform the parent of the client. Spoon, forks, straws, and tongue blades are other unacceptable items to place in the mouth of a toddler who just undergone cleft palate repair. The general principle of care is that nothing should enter the mouth until the suture line has completely healed.

2. D. The pancreatic capsules contain pancreatic enzyme that should be administered in a cold, not a hot, medium (example: chilled applesauce versus hot chocolate) to maintain the medication’s integrity.

3. B. When oral iron preparations are given correctly, the stools normally turn dark green or black. Parents of children receiving this medication should be advised that this side effect indicates the medication is being absorbed and is working well.

4. C. Reviewing the number of prescription refills the child has required over the last 6 months would be the best indicator of how well controlled and thus how effective the child’s asthma treatment is. Breakthrough wheezing, shortness of breath, and upper respiratory infections would require that the child take additional medication. This would be reflected in the number of prescription refills.

5. D. Tetracycline may cause a phototoxic reaction.

6. D. The normal heart rate of an infant is 120-160 beats per minute.

7. C. Both gentamicin and chemotherapeutic agents can cause renal impairment and acute renal failure; thus baseline renal function must be evaluated before initiating either medication.

8. C. In selecting the correct needle to administer an IM injection to a preschooler, the nurse should always look at the child and use judgment in evaluating muscle mass and amount of subcutaneous fat. In this case, in the absence of further data, the nurse would be most correct in selecting a needle gauge and length appropriate for the “average’ preschool child. A medium-gauge needle (21G) that is 1 inch long would be most appropriate.

9. C. The purpose of the salicylate therapy is to relieve the pain associated with the migratory polyarthritis accompanying the rheumatic fever. Playing mini piano would require movement of the child’s joints and would provide the nurse with a means of evaluating the child’s level of pain.

10. D. The recommended position to administer rectal medications to children is side-lying with the upper leg flexed. This position allows the nurse to safely and effectively administer the medication while promoting comfort for the child.

11. C. For a 12month-old child, 110 apical pulse rate is normal and therefore it is safe to give the digoxin. A toddler’s normal pulse rate is slightly lower than an infant’s (120).

12. B. Chest physiotherapy treatments are scheduled between meals to prevent aspiration of stomach contents, because the child is placed in a variety of positions during the treatment process.

13. C. It is common misconception that breastfeeding may prevent pregnancy.

14. B. The “security blanket” is an important transitional object for the toddler. It provides a feeling of comfort and safety when the maternal figure is not present or when in a new situation for which the toddler was not prepared. Virtually any object (stuffed animal, doll, book etc) can become a security blanket for the toddler.

15. D. Toddlers need to meet the developmental milestone of autonomy versus shame and doubt. In order to accomplish this, the toddler must be able to explore and manipulate the environment.

16. D. The introduction of a baby into a family with one or more children challenges parent to promote acceptance of the baby by siblings. The parent’s attitudes toward the arrival of the baby can set the stage for the other children’s reaction. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy.

17. D. The autonomous toddler would be frustrated by being confined to be. The pounding board and hammer is developmentally appropriate and an excellent way for the toddler to release frustration.

18. D.  It is the developmental task of an 18-month-old toddler to explore and learn about the environment. The respiratory complications associated with cystic fibrosis (which are present in almost all children with cystic fibrosis) could prevent this development task from occurring.

19. C. The best diversion for a hospitalized child aged 2-3 years old would be anything that makes noise or makes a mess; xylophone which certainly makes noise or music would be the best choice.

20. B. An 11-month-old child stands alone and can walk holding onto people or objects. Therefore the installation of a gate at the top and bottom of any stairs in the house is crucial for the child’s safety.

21. D. In second grade a child needs to form a close relationships with peers.

22. B.  A 5-year-old is highly concerned with body integrity. The preschool-age child normally asks many questions and in a situation such as this, could be expected to ask even more.

23. C. A 9-year-old enjoys working and feeling a sense of accomplishment. The school-age child also enjoys “showing off,” and doing something with the nurse on the pediatric unit would allow this. This activity also provides the school-age child a needed opportunity to interact with others in the absence of school and personal friends.

24. B. Adolescents do feel indestructible, and this is reflected in many risk-taking behaviors.

25. D. An 8-month-old infant both recognizes and is fearful of strangers. This developmental milestone is known as “stranger anxiety”.

26. A. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2 – 36.3 degree Celsius during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop approximately 0.05 degree Celsius in temperature may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2-0.4 degree Celsius. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred.

27. C.  The woman must understand that, although the “fertile” period is approximately midcycle, hormonal variations do occur and can result in early or late ovulations. To be effective, the diaphragm should be inserted before every intercourse.

28. D. Although instructions vary among birth centers, primigravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger.

29. B.  Prolactin suppresses estrogen, which is needed to stimulate vaginal lubrication during arousal.

30. B. A wood surface provides the least chance for organisms to be present.

31. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.

32. B.  A skin rash could indicate a concurrent infectious disease process in the infant. The scheduled immunizations should be withheld until the status of the infant’s health can be determined. Fevers above 38.5 degrees Celsius, alteration in skin integrity, and infectious-appearing secretions are indications to withhold immunizations.

33. C. Continuity is essential to promote active immunity and give hepatitis B lifelong prophylaxis. Optimally, the third vaccination is given 6 months after the first.

34. B. Because of the high incidence of breast cancer, all women are considered to be at risk regardless of health history.

35. B. Handwashing is the best way to prevent the spread of infection.

36. A. The purpose of the visit takes priority.

37. D. Frequent douching interferes with the natural protective barriers in the vagina that resist yeast infection and should be avoided.

38. A. Completion for the recommended schedule of infant immunizations does not require a large number of immunizations, but it also provides protection against multiple pediatric communicable and infectious diseases.

39. C. This is appropriate foods that are high in iron and calcium but would not affect lactose intolerance.

40. D. Intervention is needed when the woman thinks that she needs to wait only 6 months after being free of TB before she can get pregnant. She needs to wait 1.5-2years after she is declared to be free of TB before she should attempt pregnancy.

41. C. Salmonella organisms cause lower GI symptoms

42. C. It is a safety hazard to have shiny floors and scattered rugs because they can cause falls and rugs should be removed.

43. C. Condoms do not prevent ALL forms of sexually transmitted diseases.

44. A.  Pregnancy is one contraindication to breast-feeding. Milk secretion is inhibited and the baby’s sucking may stimulate uterine contractions.

45. C.  Perianal itching is the child’s chief complaint associated with the diagnosis of pinworms. The itching, in this instance, is often described as being “intense” in nature. Pinworms infestation usually occurs because the child is in the anus-to-mouth stage of development (child uses the toilet, does not wash hands, places hands and pinworm eggs in mouth). Teaching the child hand washing before eating and after using the toilet can assist in breaking the cycle.

46. C.  Severe itching of the scalp is the classic sign and symptom of head lice in a child. In turn, this would lead to the nursing diagnosis of “altered comfort”.

47. C. Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.

48. C. The primary goal is to prevent the spread of the disease to others. The child should experience no complication. Although the health department may need to be notified at some point, it is no the primary goal. It is also important to prevent discomfort as much as possible.

49. A. Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.

50. D.  The question asks about the immediate concern. The ABCs of community health care are always attending to people’s basic needs of food, shelter, and clothing






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