What is the most common cause of neurologic dysfunction associated with spinal cord injury?
A patient exhibits acute hypervigilance, refusal of treatment, impulsive acts, and hallucinations alternating with lucidity. Family members argue about the hallucinations. The nurse should:
One hour after starting a continuous IV insulin, a patient’s glucose drops by 145 mg/dL. What should the nurse monitor for?
What is the best method to ensure parents of a child with a new tracheostomy are adequately prepared for home care?
An infant is diagnosed with a proximal esophageal atresia with a distal fistula. A nurse should anticipate:
A child is heading to the OR for internal injuries. The parents refuse blood products due to religious beliefs. What should the nurse do first?
For a child with disseminated intravascular coagulation (DIC), administration of fresh frozen plasma (FFP) will replace:
A 6-year-old child is admitted following ingestion of an unidentified substance. Assessment reveals:
BP: 120/84
HR: 190
RR: 44
ECG: Sinus rhythm with occasional PVCs
Dilated pupils
Dry mucous membranes
Disorientation
Urinary retention
These findings are consistent with ingestion of:
CSF analysis shows: glucose 36 mg/dL, protein 110 mg/dL, and WBCs (PMNs) 1,000/microliters. These findings are indicative of:
During ablation of a child's marrow in preparation for bone marrow transplantation, a nurse should monitor for which of the following complications?
A patient has a large intracranial hemorrhage and loss of brainstem reflexes. Prior to official brain death declaration, which must be ensured?
In diabetic ketoacidosis (DKA), gluconeogenesis is a compensatory mechanism for a perceived deficiency in:
A medical team recommends a tracheostomy for an infant with spinal muscular atrophy. The parent states, “I just want to make sure my child has the best life.” The nurse should:
An infant is admitted with tonic-clonic movement of the lower extremities. The most likely etiology of the seizure is:
A recently deceased patient's family begins arriving to the ICU, visibly distraught and wailing. What is the nurse's first action?
An infant in need of a transfusion of PRBCs has only one IV access site with maintenance fluids infusing. After receiving orders to hold the maintenance fluids and administer PRBCs, the nurse should be sure to monitor which of the following?
An adolescent’s sleep is disrupted by alarms and blood draws. What is the nurse’s best action?
A 3-year-old heart transplant patient is experiencing signs of rejection. Which of the following best supports this?
A child with short bowel syndrome presents with fever, dehydration, and weight loss. To ensure nutrition, the nurse should anticipate:
A child presents with a 5-day history of fever, cervical lymphadenopathy, strawberry tongue, joint pain, and elevated CRP/ESR. The nurse should anticipate an order for:
A 17-year-old presents with history of progressive exercise intolerance. He is admitted with a diagnosis of hypertrophic cardiomyopathy. The vital signs are as follows:
BP: 78/55
HR: 110
RR: 20
T: 98.3°F (36.8°C)
SpO₂: 89% on room air
The patient's vital signs reflect:
A patient has been declared brain dead. A nurse would like the family to consider organ donation but has never requested this from a family before. The best initial action by the nurse is to:
A family member asks permission to visit a patient after work at 12:30 AM. On previous visits, the family member has been disruptive. To address the situation, a nurse should:
In a child with a closed head injury, the presence of which of the following is most commonly associated with significant morbidity or mortality?
The family member of a patient who is receiving mechanical ventilation is to be taught suctioning. When developing a teaching plan, the nurse should first:
A patient with suspected abdominal compartment syndrome has a bladder pressure of 8 mmHg. Which of the following actions should the nurse take first?
A transgender adolescent requests to be addressed by preferred name/pronouns, different from medical record. What is the best response?
An adolescent is admitted with toxic shock syndrome. In addition to blood cultures, which of the following lab orders should a nurse anticipate?
During an exchange transfusion for sickle cell crisis, the patient becomes anxious and reports tingling and numbness around the mouth. The nurse should administer:
Which of the following interventions is most effective in preventing pulmonary vasospasm in an infant with persistent pulmonary hypertension of the newborn (PPHN)?
A stat abdominal x-ray reveals free air and a large loculated fluid collection presumed to be blood. The priority of care should be:
Which action best facilitates a family’s response to discharge from ICU to a medical-surgical unit after a 3-week stay?
A 6-year-old with WPW syndrome and SVT episodes is admitted. What intervention is anticipated?
For a 20-kg child experiencing abdominal hemorrhaging, a nurse should expect to administer a fluid bolus of:
Which of the following is contraindicated when caring for a child with asthma who is intubated and receiving mechanical ventilation?
A patient has a right groin central venous catheter with vasoactive infusions. The nurse notices swelling and increased circumference of the right thigh and calf. The first action should be to:
A child’s ABG reveals pH 7.58, PaCO₂ 40, HCO₃ 30. What electrolyte change is expected?
Three weeks post-traumatic brain injury, a child has a GCS of 3, no cough or gag, and only agonal respirations. When the family asks about options of care, the nurse should respond:
An 18-month-old child is irritable and restless. Retractions, grunting with crackles, and an S3 gallop are noted. Vital signs:
BP: 70/56
HR: 160
RR: 60
Temp: 99°F (37.4°C)
Which of the following types of shock is this patient most likely experiencing?
Following a traumatic brain injury, an intubated 2-year-old patient requires an infusion of cisatracurium (Nimbex) to assist with intracranial pressure. On day 3, the ventilator’s mean airway pressure begins to alarm frequently and suctioning needs have increased. The patient’s vital signs are:
BP: 99/58
HR: 148
RR: 20
T: 102.2°F (39°C)
ICP: 19
CPP: 53
WBC: 22,000
Na⁺: 153 mEq/L
A nurse should anticipate the patient will require:
Following resuscitation of a 2-year-old near-drowning patient, which of the following changes is indicative of a poor neurologic outcome?
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TESTED 16 Jun 2025
