1. A nurse is assisting with the care of a child who is postoperative and received a

transfusion during a surgical procedure. Which of the following findings indicates

the child is havig a hemolytic reaction?

a) Chills and flank pain (Chills and flank pain are findings that indicate an

incompatibility of the transfused blood product with the client's blood. The nurse

should identify this finding as an indication that the child is having a hemolytic

reaction.)

b) Pruritus and flushing

c) Rales and cyanosis

d) Bradycardia and diarrhea

2. A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler.

Which of the following should the nurse include in the teaching?

a) "It is recommended that the toddler consumes no more than 12 ounces of fruit

juice each day."

b) "An appropriate serving size is 1 tablespoon of food per year of age." (The nurse

should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of

food per year of age.)

c) "Introduce healthy finger foods like carrots and celery sticks."

d) "Encourage 5 cups of low-fat milk each day."

3. A nurse is collecting data from an infant during a well-child visit. Which of the

following sites should the nurse use when obtaining the infant’s heart rate?

a) Apical (The nurse should use the apical pulse to obtain the infant's heart rate and

count it for a full minute, because it gives a reliable rate and rhythm and provides

accurate baseline assessment data. In an infant, the apical heart rate is auscultated

at the fourth intercostal space lateral to the midclavicular line.)