Question

A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

1.5

Rationale :

🔷 The nurse is required to administer 15 mg of morphine.

🔷The available concentration is 10 mg/mL.

🔷 Using the formula:

Volume to administer = Dose ordered ÷ Dose on hand

15 mg ÷ 10 mg/mL

1.5 mL

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Perform a neurovascular check of the lower extremities.

Rationale :

🔷 Neurovascular checks are essential for early detection of compartment syndrome, a serious complication after casting that may result from swelling or compression of tissues inside the cast.

🔷 The assessment includes evaluating the 6 Ps: pain, pallor, pulses, paresthesia, paralysis, and poikilothermia (temperature of the limb). These signs are vital for determining tissue perfusion.

🔷 A newly applied plaster cast can restrict circulation if swelling occurs underneath, so frequent assessment is crucial in the first 24 hours post-application.

🔷 Children may not verbalize discomfort accurately, making objective assessment (capillary refill, color, temperature) even more important in pediatric clients.

🔷 Early intervention upon detecting neurovascular compromise can prevent permanent nerve damage or limb ischemia, preserving function and circulation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

The child is not able to extend the leg when the thigh is flexed anteriorly at the hip

Rationale :

🔹 Kernig’s sign is a diagnostic indicator of meningeal irritation, such as in bacterial meningitis, where inflammation leads to nerve root stretching pain.

🔹 The test involves flexing the child’s hip and then extending the knee, which elicits pain or resistance if positive, due to inflamed meninges and spinal nerves.

🔹 This sign is more reliably assessed in older children and adolescents, not infants, and helps differentiate meningitis from other causes of fever.

🔹 A positive Kernig’s sign suggests the presence of subarachnoid inflammation, requiring urgent antibiotic therapy to prevent neurologic damage.

🔹 Its presence along with Brudzinski’s sign and signs of increased intracranial pressure often confirms a clinical diagnosis of meningitis pending CSF analysis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Turn the client to a lateral position.

Rationale :

🔸 The priority during a seizure is airway protection. Turning the child to the side allows secretions (saliva, vomit, blood) to drain, minimizing aspiration risk.

🔸 The lateral position helps maintain an open airway naturally, without requiring active airway maneuvers, which may be unsafe during seizure activity.

🔸 Do not insert anything in the mouth during seizures — turning the child laterally is the safest and most effective first action.

🔸 This position also reduces the risk of hypoxia or cyanosis, which are common during generalized tonic-clonic seizures.

🔸 Seizure management follows the ABCs (Airway, Breathing, Circulation); turning to a side-lying position ensures that A (airway) is protected before other interventions like oxygen or medications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Avoid giving salicylate-containing medications to a child who has viral symptoms.

Rationale :

🟪 Reye's syndrome is a rare but potentially fatal condition that causes liver dysfunction and cerebral edema, primarily seen in children recovering from viral illnesses.

🟪 Salicylates (like aspirin) are directly linked to the onset of Reye’s syndrome when given during or after a viral illness, particularly influenza and varicella.

🟪 Parents must be educated to read medication labels and avoid giving aspirin or products containing salicylates, including bismuth subsalicylate (Pepto-Bismol).

🟪 The disease presents with vomiting, confusion, lethargy, and eventually seizures or coma. Prevention through medication safety education is the most effective strategy.

🟪 The CDC and AAP both recommend strict avoidance of aspirin in individuals under 19 years of age unless specifically prescribed for certain conditions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

Rationale :

🔷 Cerebral palsy (CP) is a non-progressive but permanent neurological condition that primarily affects motor control, resulting from brain injury or abnormal development in utero or early infancy.

🔷 The disorder leads to muscle stiffness (spasticity), weakness, involuntary movements, and impaired coordination, depending on the type and severity.

🔷 CP is often associated with delays in reaching developmental milestones, such as sitting, walking, or speaking, due to poor voluntary muscle control.

🔷 Although cognitive function may be affected in some children, CP is primarily a motor disorder, and many children with CP have normal intelligence.

🔷 Management includes multidisciplinary care: physical therapy, occupational therapy, orthopedic interventions, and sometimes pharmacologic management (e.g., baclofen, botulinum toxin) to manage spasticity and improve quality of life.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Administer corticosteroid medications as prescribed
Administer bronchodilator medications as prescribed

Rationale :

🔹 Corticosteroids such as prednisone or methylprednisolone are used during exacerbations to reduce airway inflammation and prevent further bronchial edema.

🔹 These drugs help stabilize the airways and reduce mucus production, promoting better airflow.

🔹 They are usually given orally or intravenously depending on severity, and they enhance the response to β2-agonists (e.g., albuterol).

🔹 Steroids do not work immediately but are essential to prevent late-phase asthma reactions.

🔹 Early administration decreases the likelihood of hospitalization or prolonged exacerbation.

🔹 Bronchodilators, especially short-acting β2-agonists (e.g., albuterol), relax smooth muscle in the bronchial wall, relieving acute bronchospasm.

🔹 They are the first-line treatment in acute asthma attacks and provide rapid symptomatic relief.

🔹 Delivered via nebulizer or metered-dose inhaler with spacer, they improve oxygenation and ventilation.

🔹 These medications are critical for restoring airway patency during an exacerbation.

🔹 Frequent assessment post-administration ensures effectiveness and detects adverse effects like tachycardia or tremors.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

High-pitched cry

Rationale :

🔸 A high-pitched, shrill cry is a hallmark sign of increased intracranial pressure (ICP) in infants, often seen with bacterial meningitis.

🔸 It indicates neurologic irritation or discomfort and is usually distinct from the normal infant cry — it is persistent and difficult to soothe.

🔸 In meningitis, inflammation of the meninges and brain increases pressure in the cranial vault, which infants express through non-verbal signs like this cry.

🔸 Other associated signs include irritability, vomiting, bulging fontanel, and seizures in advanced cases.

🔸 Early recognition of this cry can lead to prompt lumbar puncture and initiation of antibiotics, reducing the risk of permanent neurologic damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

A decrease in urine output

Rationale :

🟪 A decrease in urine output in a child in skeletal traction could indicate compartment syndrome, where increasing pressure compromises blood flow and tissue perfusion.

🟪 Compartment syndrome may reduce renal perfusion if systemic circulation is impaired, especially in the presence of hypovolemia or unrelieved pain.

🟪 Urine output is a critical indicator of kidney function and overall perfusion, and oliguria or anuria may reflect a serious complication.

🟪 Monitoring intake and output is essential in traction to evaluate for complications such as dehydration, hypovolemia, or sepsis.

🟪 This finding must be reported immediately, as prolonged poor perfusion to tissues and organs can result in acute kidney injury or permanent limb damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Place resuscitation equipment at child's bedside

Rationale :

🟨 Epiglottitis is a life-threatening bacterial infection (often caused by Haemophilus influenzae type B) that causes rapid swelling of the epiglottis, obstructing the airway.

🟨 The condition can deteriorate within minutes, so emergency intubation or tracheostomy may be required at any time.

🟨 Resuscitation equipment — including a bag-valve mask, intubation tray, oxygen, and suction — must be readily accessible.

🟨 The nurse should avoid examining the throat with a tongue blade, as this could trigger complete airway obstruction.

🟨 Prioritizing readiness for respiratory failure ensures the child’s airway can be secured before cyanosis, apnea, or arrest occurs.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2 :
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

3 :
The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is a characteristic of this sign?

4 :
A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

5 :
The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in this teaching?

6 :
The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

7 :
Which interventions should be implemented for a pediatric client experiencing an asthma exacerbation? (SELECT ALL THAT APPLY)

8 :
A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

9 :
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

10 :
A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?

QLexNursing

1 : A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2 : A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

3 : The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is a characteristic of this sign?

4 : A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

5 : The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in this teaching?

6 : The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

7 : Which interventions should be implemented for a pediatric client experiencing an asthma exacerbation? (SELECT ALL THAT APPLY)

8 : A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

9 : The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

10 : A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?

1 :
A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

2 :
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

3 :
The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is a characteristic of this sign?

4 :
A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

5 :
The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in this teaching?

6 :
The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

7 :
Which interventions should be implemented for a pediatric client experiencing an asthma exacerbation? (SELECT ALL THAT APPLY)

8 :
A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?

9 :
The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

10 :
A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform?