Question

A Nurse was attending to a patient

Answer 1

Correct Answers

Blank 1 Correct Option: Hypoglycemia
Blank 2 Correct Option: Provide glucose source and Check blood glucose level
Blank 3 Correct Option: Toleration of tapering down in last hour of infusion and Blood glucose levels

Rationale :

Condition: Hypoglycemia

📌The client receiving parenteral nutrition (PN) presents with shakiness, headache, sweating, nausea, and weakness, which are classic signs of hypoglycemia.

📌PN solutions are high in dextrose, and abrupt interruption or delayed administration can cause a rapid drop in blood glucose levels, especially if insulin secretion continues after glucose supply is stopped.

📌Additionally, the client is NPO (nothing by mouth), so they lack an oral glucose source to stabilize their blood sugar when PN flow changes.

📌Therefore, the client’s current symptoms are most consistent with hypoglycemia related to PN interruption rather than infection or fluid overload.

💎 Action 1: Check blood glucose level

🔹 First priority: Assess the client’s capillary blood glucose immediately to confirm hypoglycemia.

🔹 This determines the severity and guides subsequent interventions (e.g., whether to give IV dextrose).

🔹 Checking glucose helps differentiate hypoglycemia from other causes of dizziness or weakness, such as infection or dehydration.

🔹 Always check glucose before altering PN rate or calling the provider, as rapid identification prevents neurologic complications.

💎 Action 2: Provide glucose source

🔹 If blood glucose is below 70 mg/dL, the nurse should administer a glucose source immediately — typically IV 10% or 50% dextrose if the client is NPO or on PN.

🔹 This stabilizes blood sugar and relieves acute symptoms like tremors and sweating.

🔹 For PN clients, it’s critical to avoid abrupt discontinuation of the PN infusion. If PN must be paused, hang 10% dextrose (D10W) to prevent rebound hypoglycemia.

🔹 Follow-up includes rechecking glucose after 15 minutes and documenting the response.

💎 Parameter 1: Blood glucose levels

🔹 Frequent monitoring of blood glucose every 4–6 hours (or per protocol) ensures early detection of fluctuations.

🔹 During PN therapy, glucose can swing high or low depending on infusion rate or interruptions.

🔹 The goal is to maintain glucose levels within a safe range (typically 70–140 mg/dL) to avoid metabolic instability.

🔹 Continuous tracking helps in adjusting PN composition and tapering schedules safely.

💎 Parameter 2: Toleration of tapering down in last hour of infusion

🔹 PN infusions should be gradually tapered down over 1–2 hours rather than stopped suddenly.

🔹 Tapering allows the body to adjust insulin secretion and prevents rebound hypoglycemia as dextrose supply decreases.

🔹 During this tapering, monitor for return of hypoglycemic symptoms like sweating, tremors, or confusion.

🔹 Document how the client tolerates tapering and whether additional glucose support is needed.

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Answer 2

Correct Answers:

"My daughter becomes short of breath and tired when she plays with her sister."

Rationale :

💎 Exercise intolerance — In children, fatigue and dyspnea during activity (e.g., playing or running) are hallmark signs of heart failure (HF). The heart cannot pump enough oxygenated blood to meet metabolic demands during exertion.

💎 Decreased cardiac output leads to poor perfusion, causing the child to tire easily and need frequent rest breaks.

💎 Shortness of breath (dyspnea) occurs because of pulmonary congestion—fluid backs up into the lungs, making it hard to breathe during exertion.

💎 Behavioral signs like avoiding play, preferring quiet activities, or lying down after minimal effort often appear early in pediatric HF, making this parent’s observation highly indicative.

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Answer 3

Correct Answers:

Teaching is based on the senses-what the client will see, hear, and feel during and after the procedure.

Rationale :

🧸 School-age children (6–12 years) think concretely, so teaching should focus on sensory experiences — what they’ll see, hear, and feel before and after surgery.

🧸 Providing realistic details like IV lines, monitors, and noises helps the child reduce anxiety through familiarity.

🧸 Using medical play, pictures, or models engages their curiosity and encourages participation and understanding.

🧸 This approach helps the child feel prepared and in control, promoting cooperation on the day of surgery.

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Answer 4

Correct Answers:

The client's heart rate is reduced.
The left pupil is larger than the right pupil.

Rationale :

The client's heart rate is reduced (bradycardia).

🧠 Bradycardia in a post-craniotomy child is a classic component of Cushing’s triad (↓HR, ↑SBP with widened pulse pressure, irregular respirations), signaling rising intracranial pressure and brainstem compression.

🧠 As ICP rises, vagal (parasympathetic) output increases, slowing the SA node and producing sustained bradycardia—this is pathologic, not a benign postoperative fluctuation.

🧠 Persistent bradycardia alongside altered mentation, vomiting, or blood pressure changes suggests impending herniation and requires immediate escalation (notify provider, prepare for ICP-lowering interventions).

🧠 Corroborate with other neuro signs (LOC trend, blood pressure pattern, respiratory irregularity) and avoid procedures that raise ICP (excess suctioning, pain, agitation).

The left pupil is larger than the right pupil (anisocoria).

👁️New unequal pupils imply third-nerve (CN III) compression from localized swelling, hematoma, or mass effect, all of which can occur with increasing ICP.

👁️ The enlarged or sluggish pupil on the affected side reflects uncal/temporal pressure on the nerve and midbrain, a red-flag sign for neurologic deterioration.

👁️ Pupil asymmetry often precedes dramatic LOC decline, so prompt action (urgent provider notification, readiness for osmotic therapy, imaging) can be limb- and life-saving.

👁️ Assess and document PERRLA trends (size in mm, reactivity, symmetry) hourly or per protocol; any acute change is treated as emergent.

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Answer 5

Correct Answers:

"This condition is best treated with a barrier cream or ointment."

Rationale :

👶 Diaper dermatitis caused by irritation from urine or stool after diarrhea is contact dermatitis, not infection.

👶 Applying barrier creams with zinc oxide or petrolatum protects the skin from further breakdown.

👶 Encourage frequent diaper changes and allow air exposure to promote healing.

👶 Avoid antifungal or antibiotic creams unless there are signs of infection such as pustules or satellite lesions.

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Answer 6

Correct Answers:

"I think I will have an implant inserted."
"Perhaps an intrauterine device is a good choice for me."
"I think the medroxyprogesterone injection is a good choice."

Rationale :

"I think I will have an implant inserted."

💉

.📌The contraceptive implant (e.g., etonogestrel) provides up to 3 years of continuous pregnancy prevention

.📌It is discreet and invisible, meeting the client’s need for privacy from her partner.

.📌The method requires no daily action, eliminating the worry about forgetting pills.

.📌Effectiveness exceeds 99%, making it one of the most reliable reversible methods.

.📌Ideal for clients who want long-term contraception without frequent medical visits.

"Perhaps an intrauterine device is a good choice for me."

🔷

.📌The IUD is a long-acting reversible contraceptive (LARC) lasting 3–10 years depending on type.

.📌It is highly effective and requires no daily or weekly adherence.

.📌The IUD is private and partner-invisible, suitable for someone who wants confidentiality.

.📌Once inserted, it offers consistent protection without routine maintenance.

.📌Fertility returns quickly once it is removed, providing reproductive flexibility later.

"I think the medroxyprogesterone injection is a good choice."

💠

.📌The Depo-Provera injection provides 3 months of protection with a single shot.

.📌It is confidential, as no external devices or pills are visible to others.

.📌This method is perfect for clients who may forget daily pills or travel frequently.

.📌It also reduces menstrual cramps and bleeding, which many teens find beneficial.

.📌Requires quarterly follow-up only, making it convenient and low-maintenance.

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Answer 7

Correct Answers:

Exercise increases the tidal volume and improves airway clearance.

Rationale :

🏃 In cystic fibrosis, thick mucus blocks airways; exercise helps by expanding lungs and improving mucus clearance.

🏃 Activities such as swimming or jogging increase tidal volume and strengthen respiratory muscles.

🏃 Regular exercise reduces pulmonary infections and supports better oxygen exchange.

🏃 Teach the child to maintain hydration and rest periods while staying active.

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Answer 8

Correct Answers:

"The tube will allow for her to get feedings until they can repair her defect fully."

Rationale :

💥The tracheoesophageal fistula (TEF) involves an abnormal connection between the trachea and esophagus, causing aspiration risk if oral feeding occurs.

💥A gastrostomy tube (G-tube) is placed to provide nutritional support directly into the stomach, bypassing the defective esophagus.

💥This allows the child to receive adequate calories and hydration while the defect heals or until further surgical correction is possible.

💥The G-tube feeding prevents aspiration pneumonia and maintains growth and development during the recovery period.

💥Once the esophageal repair is complete and swallowing is safe, the child can gradually transition to oral feeds.

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Answer 9

Correct Answers:

Place gown, masks, and gloves outside the room.

Rationale :

♦️Respiratory syncytial virus (RSV) is transmitted by droplet and contact routes, so contact and droplet precautions must be in place.

♦️Gowns, masks, and gloves should be readily available outside the room for anyone entering to prevent the spread of infection.

♦️A private room or cohorting with another RSV patient is appropriate, but negative or positive pressure rooms are not required.

♦️The UAP should ensure that visitors and staff don protective equipment before entry and remove it before leaving.

♦️This practice reduces nosocomial transmission among pediatric clients and healthcare personnel.

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Answer 10

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

Step 1 — Assess the airway and breathing (2)

👶 Check ABCs first: look for drooling, stridor, hoarseness, cough, respiratory distress.

👶Keep the child NPO, place on pulse oximetry, have suction ready, provide O₂ as needed.

👶Minimize stimulation; prepare for urgent airway support (anesthesia/ENT) if signs of compromise appear.

Step 2 — Call the poison control center (4)

☎️ Provide age/weight, exact product name/ingredients, time/amount ingested, and current symptoms.

☎️Follow their evidence-based guidance for this specific caustic (strong acid/alkali), and document recommendations.

☎️Do NOT induce vomiting or attempt neutralization; risk of re-burn and heat generation.

Step 3 — Administer activated charcoal (1) — only if poison control directs

🧪 For caustics, charcoal is usually contraindicated (poor adsorption, obscures endoscopy, aspiration risk).

🧪If poison control specifically recommends it (rare in caustics), ensure protected airway and correct dose/route per protocol.

Step 4 — Administer the prescribed laxative (3) — only if advised

🚸 Cathartics are not routine for caustic ingestions; use only if poison control/tox recommends to enhance elimination of non-caustic co-ingestants.

🚸Monitor for dehydration and electrolyte shifts in toddlers.

Step 5 — Instruct the family about black stools (5)

📝 If charcoal was given, explain it can cause black stools and dark emesis, which is expected.

📝Review red flags to report: worsening breathing, persistent drooling, chest/abdominal pain, vomiting, fever.

📝Reinforce poison-proofing the home (locked, original containers) and the need for any scheduled follow-up (e.g., GI/endoscopy if ordered).

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Examplify CJE Pediatrics Benchmark 1 2025

No.

1 :
A Nurse was attending to a patient

Correct Answers

2 :
A 4-year-old is seen in the primary care clinic. The child has a history of a repaired congenital heart defect and has been treated frequently for heart failure. The parent is describing their child's symptoms. Which parent statement most closely describes heart failure in children?

3 :
A 10-year-old is to undergo ureteral re-implants for vesicoureteral reflux. The nurse and child life therapist provide pre-operative education for the client and parents. On which of these principles should they base the teaching?

4 :
The nurse cares for a 6-year-old who had surgical resection of a brain tumor the previous day. The nurse assesses the client's neurological status. Which findings alert the nurse to an increase in intracranial pressure? Select all that apply.

7 :
A nurse encourages a school-age child with cystic fibrosis to engage in exercise. In planning a teaching session with the client, which factor should the nurse include in the teaching?

9 :
A 6-month-old with respiratory syncytial virus bronchiolitis is admitted to the unit. The nurse provides direction to the unlicensed assistive personnel (UAP). Which action does the nurse instruct the UAP to perform to provide appropriate isolation precautions?

10 :
A 2-year-old is brought to the emergency department following ingestion of a known substance. The substance is caustic, and the child is alert and active. Using the unit's ingestion protocol, place the interventions in the order they should be implemented by the nurse. Items to be Ordered

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Examplify CJE Pediatrics Benchmark 1 2025

No.

1 : A Nurse was attending to a patient

Correct Answers

2 : A 4-year-old is seen in the primary care clinic. The child has a history of a repaired congenital heart defect and has been treated frequently for heart failure. The parent is describing their child's symptoms. Which parent statement most closely describes heart failure in children?

3 : A 10-year-old is to undergo ureteral re-implants for vesicoureteral reflux. The nurse and child life therapist provide pre-operative education for the client and parents. On which of these principles should they base the teaching?

4 : The nurse cares for a 6-year-old who had surgical resection of a brain tumor the previous day. The nurse assesses the client's neurological status. Which findings alert the nurse to an increase in intracranial pressure? Select all that apply.

7 : A nurse encourages a school-age child with cystic fibrosis to engage in exercise. In planning a teaching session with the client, which factor should the nurse include in the teaching?

9 : A 6-month-old with respiratory syncytial virus bronchiolitis is admitted to the unit. The nurse provides direction to the unlicensed assistive personnel (UAP). Which action does the nurse instruct the UAP to perform to provide appropriate isolation precautions?

10 : A 2-year-old is brought to the emergency department following ingestion of a known substance. The substance is caustic, and the child is alert and active. Using the unit's ingestion protocol, place the interventions in the order they should be implemented by the nurse. Items to be Ordered

1 :
A Nurse was attending to a patient

2 :
A 4-year-old is seen in the primary care clinic. The child has a history of a repaired congenital heart defect and has been treated frequently for heart failure. The parent is describing their child's symptoms. Which parent statement most closely describes heart failure in children?

3 :
A 10-year-old is to undergo ureteral re-implants for vesicoureteral reflux. The nurse and child life therapist provide pre-operative education for the client and parents. On which of these principles should they base the teaching?

4 :
The nurse cares for a 6-year-old who had surgical resection of a brain tumor the previous day. The nurse assesses the client's neurological status. Which findings alert the nurse to an increase in intracranial pressure? Select all that apply.

7 :
A nurse encourages a school-age child with cystic fibrosis to engage in exercise. In planning a teaching session with the client, which factor should the nurse include in the teaching?

9 :
A 6-month-old with respiratory syncytial virus bronchiolitis is admitted to the unit. The nurse provides direction to the unlicensed assistive personnel (UAP). Which action does the nurse instruct the UAP to perform to provide appropriate isolation precautions?

10 :
A 2-year-old is brought to the emergency department following ingestion of a known substance. The substance is caustic, and the child is alert and active. Using the unit's ingestion protocol, place the interventions in the order they should be implemented by the nurse. Items to be Ordered