Nokea
A mother calls the clinic to talk to the nurse. The mother states that a physician described her daughter as having 20/60 vision and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which of the following?
- A. A loss of approximately one-third of her vision.
- B. Ability to see at 60 feet what she should see at 20 feet.
- C. Ability to see at 20 feet what she should see at 60 feet.
- D. Visual acuity three times better than average.
Correct Answer: C
Rationale: 20/60 vision means the child sees at 20 feet what a person with normal vision sees at 60 feet.
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Initiation of which of the following immunizations is recommended prior to the adolescent entering college?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP).
- B. Varicella.
- C. Meningococcal.
- D. Pneumococcal conjugate vaccine (PCV).
Correct Answer: C
Rationale: Meningococcal vaccine is recommended before college due to increased risk in dormitories.
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.
A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and:
- A. An 18-month-old with RSV.
- B. A 9-year-old 8 hours post-appendectomy.
- C. A 1-year-old with a heart defect.
- D. A 6-year-old with sickle cell crisis.
Correct Answer: C
Rationale: Assigning the same nurse to a child with RSV and a 1-year-old with a heart defect should be avoided due to the risk of transmitting RSV, which can be particularly severe in children with cardiac conditions.
Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency anemia?
- A. Rice cereal, whole milk, and yellow vegetables.
- B. Potato, peas, and chicken.
- C. Macaroni, cheese, and ham.
- D. Pudding, green vegetables, and rice.
Correct Answer: B
Rationale: Chicken and peas are iron-rich, supporting anemia treatment. Other options lack sufficient iron sources.
While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next?
- A. Assess the neurologic status of the toes.
- B. Determine the circulatory status of the upper thigh.
- C. Obtain the child's vital signs.
- D. Notify the physician immediately.
Correct Answer: D
Rationale: Swelling, pain, and refusal to walk suggest a serious injury, possibly a fracture, requiring immediate physician notification.