NCLEX Practice Questions — Set 24
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The nurse is instructing an older adult client who has been prescribed a hypnoticfor insomnia. Which of the following instructions should be given?
Show answer and rationale
Correct answer: A. "Ask for help getting out of bed."
Hypnotics may cause ataxia and confusion, increasing the risk of falls and fractures. Hypnotics will not increase the appetite, result in irritability, or cause extrapyramidal adverse reactions.
The nurse should administer which of the following drugs to a client who is severely ill with schizophrenia, does not respond to conventional antipsychotic drugs, and has suicidal ideations?
Show answer and rationale
Correct answer: C. Clozapine (Clozaril)
Haloperidol (Haldol) is an antipsychotic used to treat manic states, drug-induced psychoses, and schizophrenia. Chlorpromazine (Thorazine) is an antipsychotic used to treatacute and chronic psychoses, schizophrenia, and the manic phase of manic-depression. Risperidone (Risperdal) is an antipsychotic used in the treatment of schizophrenia. Clozapine (Clozaril) is an antipsychotic used to treat severely ill schizophrenic clients who do not respond to conventional antipsychotic therapy and have suicidal ideations. It carries a risk of life-threatening agranulocytosis.
Which of the following interventions is a priority and will help the older adult client comply with the drug regimen?
Show answer and rationale
Correct answer: C. Educate the client on ways to manage adverse reactions
The priority intervention is to educate the client on how to manage the adverse reactions of the drugs. Unpleasant adverse reactions are often the reason for noncompliance with drugs. Educating the family members reinforces the education given the client. It should not be the priority intervention because it takes away the control from the client. Counting the number of pills left in the bottle at each appointment with the physician and calling the client as a reminder to take the pills as prescribed also take away the control from the client and display a sense of distrust.
The nurse reads in the record that the client is receiving a stimulant drug. The nurse reviews the medical record and administers which of the following drugs?
Show answer and rationale
Correct answer: D. Modafinil (Provigil)
Modafinil (Provigil) is an analeptic drug administered to improve wakefulness in clients with excessive daytime sleepiness associated with narcolepsy. Buspirone (BuSpar) and�alprazolam (Xanax) are antianxiety drugs.�Amitriptyline (Elavil) is an antidepressant drug.
The nurse is preparing to delegate nursing tasks to a licensed practical nurse. Which of the following may be delegated to a licensed practical nurse?
Show answer and rationale
Correct answer: D. Assist a client taking a monoamine oxidase inhibitor to select a menu with foods low in tyramine
A licensed practical nurse may assist a client taking a monoamine oxidase inhibitor to select a low-tyramine diet. The instructional teaching that must be performed by a registered nurse has already taken place and now the focus changes to assisting a client to select appropriate foods. It would not be appropriate to assess the parents of a child taking a stimulant for abuse unless there is an indication of potential abuse. Providing the family and client information on the adverse reactions to a drug and informing the client of potential complications should be performed by a registered nurse.
Based on an understanding of Erikson’s stages of psychosocial development, which of the following is a priority to communicate to the parents of an infant to assist them in meeting the basic needs of infancy?
Show answer and rationale
Correct answer: A. Attend to the infant’s need for comfort, security, predictability, food, and warmth
During infancy, trust is developing, which means that the infant’s basic needs must consistently be met by reliable, nurturing caregivers, usually the parents. If these needs are not met, there is a danger that mistrust will occur.
The nurse is assessing a toddler’s psychosocial developmental level using Erikson’s eight stages. Which of the following behaviors would the nurse most likely find if the child were demonstrating being in shame and doubt instead of having mastered autonomy?
Show answer and rationale
Correct answer: B. Dependency and constantly looking to others for approval
Autonomy versus shame and doubt is Erikson’s stage for toddlers. Autonomy develops as children discover their new mental and physical abilities while improving language and motor skills and learning competencies related to independence (bathing, eating, toileting). Doubt occurs if children learn to mistrust not only themselves but also the immediate environment. Children demonstrating dependency and constantly needing approval for their actions have not resolved this conflict.
A preschooler knows ramming a tricycle into the garage door at home is not an acceptable behavior but does this at a friend’s house. Which of the following statements by the nurse is the most appropriate reason for this difference in behavior at home and at the friend’s house?
Show answer and rationale
Correct answer: C. "A young preschool child may have difficulty applying known rules to a different situation."
Preschool children are in the preconventional level of moral development. They are learning to conform their behavior to the expectations of others, but are not able to transfer reasons for their behavior to a different situation or environment, especially when the person rewarding them for good behavior is not always around.
The nurse is assessing four newborns and evaluates which of the following findings to be consistent with physiologic or normal jaundice?
Show answer and rationale
Correct answer: D. A gradual rise in bilirubin to 8 mg/dl on day 3 to 5 after birth
Physiologic or normal jaundice shows a gradual rise in bilirubin of 8 mg/dl at 3 to 5 days after birth. The level falls to normal the second week of life. If the un conjugated level is greater than 12 mg/dl when the baby is formula-fed, greater than 14 mg/dl if the baby is breast-fed, or if the jaundice is persistent past 2 weeks of age, further evaluation is warranted.
Which of the following should the nurse include in the immediate care instructions given to the parents of a newborn circumcised with a plastic bell?
Show answer and rationale
Correct answer: D. Gently lift the ring and squeeze warm water from a cotton ball onto the tip of the penis when changing the diaper
The immediate care of the circumcised newborn is dependent on the procedure performed. If the plastic bell was utilized, it is left on the penis. Gently lift the ring and squeeze warm water from a cotton ball onto the�tip of the penis when changing the diaper. The ring will fall off in 7 to 10 days when the circumcision has healed.
The mother of a breast-fed newborn tells the nurse that the baby’s stool is golden yellow, pasty instead of firm, and has a sour milk odor. Which of the following would be the best response by the nurse?
Show answer and rationale
Correct answer: B. "This is a normal stool for a newborn who is breast-fed."
Transition stools of the newborn are greenbrown to yellow-brown in color. They occur by the third day. Breast-fed infants’ stool is yellow to golden, pasty, and has a sour milk odor. Formula-fed newborns’ stool is pale to light yellow, firmer than the stool of a breast-fed infant, and has a strong odor.
A mother tells the nurse that her 6-month-old child is grasping things such as a spoon in the palms and asks when the child will be able to grasp a spoon between the thumb and fingers. The appropriate response by the nurse would be which of the following?
Show answer and rationale
Correct answer: B. "This is normal for this age. The pincer grasp isn’t mastered until 8�months."
During the first month of life, a primitive grasp reflex enables the infant to hold objects with a tightly clenched fist. By the end of 2�months, this primitive reflex fades and the infant begins to actively grasp and momentarily hold an object before dropping it. At 3�months of age, the infant has the ability to hold the hand open, look at the fingers, and place them in the mouth. By 5�months, the infant can voluntarily grasp an object with the whole hand (palmar grasp) and can actively manipulate all grasped objects and place them in the mouth. Between 6 and 7�months, the infant can hold a bottle securely and willingly drop any grasped object.�The palmar grasp is replaced with a thumb-and-finger pincer grasp at approximately 8�months.
A mother expresses concern because her infant is walking sideways while holding onto furniture. Which of the following is the appropriate statement the nurse should make to this mother?
Show answer and rationale
Correct answer: D. "Infants start walking sideways while holding onto furniture before walking or standing alone."
From 10 to 12�months, infant locomotion progresses rapidly. During this time, infants will take deliberate steps while holding onto something and will walk sideways while holding onto furniture before walking or standing alone. Once infants can stand alone, they will attempt to take a few steps alone.
Which of the following should the nurse include when preparing to teach a class on the introduction of new foods during the first year of life?
Show answer and rationale
Correct answer: B. Introduce one new food at a time at 7-day intervals
Due to the potential for an allergic reaction during the infant’s first year of life, new foods should be introduced one at a time at 7-day intervals between each new food, so if the infant is allergic to the new food, it will be apparent. Generally, rice cereal is introduced first because it is least likely to cause allergies. Vegetables are offered next, followed by fruits. Vegetables are started before fruits to avoid getting the infant accustomed to the sweet taste.
The nurse evaluates which of the following four infants to have an abnormal language development?
Show answer and rationale
Correct answer: B. A 7-month-old who is beginning to vocalize during play and pleasure
It is abnormal for a 7-month-old infant to start vocalizing during play and pleasure. This is a language skill that normally develops between 3 and 6�months.
The nurse is instructing the parents of a toddler on the development of depth perception. Which of the following should the nurse instruct the parents to watch for?
Show answer and rationale
Correct answer: B. An increased fall risk when the toddler is learning to walk, run, and climb stairs
Before depth perception is fully developed, toddlers will have no sense of distance andmay not realize how far away the floor is when learning to walk, run, and climb.
Which of the following is the most ageappropriate explanation the nurse should give a toddler who is to take medication every morning for 7 days?
Show answer and rationale
Correct answer: C. "You will be taking your medicine every morning after breakfast until it is gone."
Children of this age do not have the cognitive ability to understand explanations and are better able to understand time when it is associated with a familiar activity.
A mother tells the nurse about being frustrated by the toddler saying "no" to everything said. Which of the following statements by the nurse would be most helpful to the mother?
Show answer and rationale
Correct answer: D. "This is an expression of your child’s search for autonomy that will disappear at 30�months of age."
Toddlers often resent being given directions or not being allowed to explore what they desire in an expanding environment. Often toddlers will delight in doing the opposite of what is asked and frequently respond "no" to requests.
A couple is expecting their new baby any day and both are concerned their 2-year-old will have problems accepting a new sister or brother. Which of the following statements by the parents would indicate they have acted on the teaching the nurse offered to help the toddler to deal with the birth of the sibling?
Show answer and rationale
Correct answer: C. "The grandparents have been keeping our 2-year-old frequently."
Sibling rivalry often arises when an infant is born into a family with a toddler. The arrival of the new baby can be devastating to toddlers because they now must compete for a caregiver’s attention. One way to help toddlers is to have them stay with other family members who will be caring for them when the mother is in the hospital having the new baby. Grandparents are often these family members.
A mother is expressing concern to the nurse that her 5-year-old occasionally is urinating in the underwear instead of going to the bathroom. Which of the following questions is the priority for the nurse to ask to determine if this is a normal occurrence?
Show answer and rationale
Correct answer: B. "Does this behavior occur when your child is engaged in some activity?"
It is not uncommon for preschoolers to become so engaged in their play or other interesting activities that they do not realize they need to go to the bathroom.
A mother is concerned about her preschool-age child running into the street without looking. Which of the following instructions would be the priority for the nurse to give this mother?
Show answer and rationale
Correct answer: A. Offer verbal reminders to look before crossing the street
Preschoolers have the cognitive ability to understand directions and the consequences of their behavior. However, to help them remember to behave in a certain way, they often need to be reminded.
Which of the following should the nurse include when instructing a mother to administer vitamins to a preschooler?
Show answer and rationale
Correct answer: A. Store the vitamins in a locked cabinet that the child cannot access
Multivitamins for children often taste like candy. Because preschoolers like the taste of these vitamins, they may be tempted to take more pills than needed unless the pills are stored in a locked cabinet the child has difficulty accessing.
Which of the following statements by the parents of a preschooler would indicate that the parents had implemented the nurse’s instructions on dental hygiene practices?
Show answer and rationale
Correct answer: D. "We give our child a pea-sized amount of fluoride toothpaste."
Toothpaste often contains fluoride, and young children are in danger of receiving too much.
The nurse caring for preschoolers in a day care center will find which of the following problems to be more common at this age than at any other?
Show answer and rationale
Correct answer: A. Minor illnesses such as colds, otitis media, and GI disturbances
Common illnesses of the preschool years include mostly minor illnesses, such as otitis media, colds, or gastrointestinal disturbances. In fact, minor illnesses are more common during this time than at any other time in life because this is the age at which children start playing together more frequently, attend child care, or start preschool activities and thus have greater exposure to illness.
Based on the growth and development of adolescent girls, the school nurse understands which of the following is the priority regarding body image?
Show answer and rationale
Correct answer: A. Few girls are satisfied with their physical appearance
Body image, or the mental conception of one’s physical appearance, varies with maturation and changes across time, situations, and experiences one has with others. Adolescent females are more dissatisfied with their appearance and more likely to be concerned about particular parts of their bodies than are their male counterparts.
An adolescent tells the parents that refusing to go to school on a particular day doesn’t have anything to do with not having anything appropriate to wear and having a "zit" (skin eruption) on the face. The nurse explains to the parents that this behavior exemplifies which of the following concepts?
Show answer and rationale
Correct answer: C. Imaginary audience
The imaginary audience refers to the adolescent’s belief of always being on stage and that others are always aware of the adolescent’s physical appearance.
The nurse is teaching a class of adolescents to improve their diets. Which of the following approaches would be most helpful in achieving this goal?
Show answer and rationale
Correct answer: A. Have the adolescents get involved in meal planning after receiving information on dietary needs
Adolescents always seem hungry but often do not eat appropriately. Instead they prefer snack foods that are easy to prepare, faddish, and full of empty calories. Adolescent food habits are influenced by concerns about body image, peer pressure, emotional problems, busy schedules, and unsupervised meal preparation or purchase. They also may skip meals, eat fast foods, or snack frequently. The best way to help adolescents improve their nutrition is to explain the importance of a good diet and encourage adolescents to become involved in meal planning.
The registered nurse is preparing the clinical assignments for a pediatric unit. Which of the following assignments may the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: B. Assist a toddler in walking
Clinical assignments such as skills that involve evaluation, monitoring, and instructing are activities of the registered nurse. A licensed practical nurse may assist a toddler in walking.
The nurse identifies which of the following as a characteristic of defecation in toddlers?
Show answer and rationale
Correct answer: C. Control of defecation starts between 1 and 2�years of age
Control of defecation generally starts in toddlers between 1 and 2�years of age. Preschoolers, between 3 and 6�years of age, frequently delay defecation because of play and may experience constipation.
A mother brings her infant to the clinic for a 9-month well-baby exam. She expresses concern to the nurse that her infant’s "soft spot" in the front is still palpable. The nurse’s response would be based on the understanding that the anterior fontanel closes
Show answer and rationale
Correct answer: C. before 18�months of age.
The anterior fontanel closes between 12 and 18�months of age, with average closure at 14�months. The parent of a 9-month-old should be reassured that the anterior fontanel is still palpable. The nurse should measure its size and plot it on the occipital frontal circumference chart.
A 5-year-old girl presents for a vision screen. A screening using an HOTV chart is completed with the following results: 10/15 right eye, 10/12.5 left eye. Which of the following interpretations by the nurse is correct?
Show answer and rationale
Correct answer: C. These results are considered passing and no referral is required
A 5-year-old child screened using the HOTV chart should achieve at least a 10/15 in both eyes without a two-line difference, so this is considered a passing test. An HOTV test is the preferred test for children ages 3 to 5, because most children at these ages are unable to read the letters on a Snellen chart. The recommended testing distance is 10 feet.
On testing, a 3-year-old boy is found to have left esotropia. The physician directs the nurse to instruct the parent on "patching" to treat the strabismus. The nurse should instruct the parent to place
Show answer and rationale
Correct answer: C. the patch on the right eye.
For a client with esotropia, the stronger eye should be patched to increase visual stimulation in the weaker eye, thus strengthening the eye muscles. Patching the weaker eye would worsen the problem. Patching both eyes is impractical, unnecessary, and counter to the goals of treatment. Esotropia (convergent) occurs when the eye turns toward the midline.
In addition to instructing the mother on patching, the nurse informs her that it is important that the strabismus was recognized before the age of 6�years. This reflects thenurse’s understanding that untreated strabismus may result in
Show answer and rationale
Correct answer: B. amblyopia.
Strabismus is a condition where the visual lines of the two eyes do not focus simultaneously on the same object in space because of a lack of muscle coordination, resulting in a cross-eyed appearance. If left untreated, it leads to eventual loss of vision in the weaker eye and may lead to blindness. Astigmatism, myopia, and hyperopia are disorders that, while significant, are refractory errors and can be corrected with special lenses.
To pass pure tone audiometry testing, the nurse understands that a child should be able to hear a frequency of 500 Hz at how many decibels (db)?
Show answer and rationale
Correct answer: B. 25 db
Inability to hear any frequency at 25 db is considered a failure. Most children are able to hear frequencies higher than 500 Hz at 20 db.
An 18-month-old child is to have a tympanogram. The mother asks what that is. Which of the following statements by the nurse best describes the purpose of tympanometry?
Show answer and rationale
Correct answer: C. "It is a diagnostic test that measures tympanic membrane compliance (mobility)."
Tympanometry is used to measure tympanic membrane compliance. It also estimates middle ear pressure. It does not indicate the degree of hearing loss. It is not useful in infants under age 6�months, because of hypercompliance of the tympanic membrane. It does not measure external auditory canal air pressure.
A 2-year-old boy is sent home from day care because of red, itchy eyes. The nurse notes mucopurulent discharge from both eyes, and the physician treats the boy with antibiotic eyedrops. The nurse providing discharge education recognizes a need to repeat instruction when the mother states
Show answer and rationale
Correct answer: A. "I need to clean his eyes from the outer corner inward."
The eye should be cleaned from the inner canthus of the eye downward and outward. This will lessen the potential of infecting the other eye. It would be appropriate to prevent the child from returning to day care for 24�hours after starting antibiotics to prevent spreading the infection. It is also necessary to administer the antibiotic on a regular basis and to wash the hands frequently.
The nurse evaluates which of the following laboratory tests and pathogens to cause acute otitis media in children?
Show answer and rationale
Correct answer: D. Haemophilus influenzae and Streptococcus pneumoniae
H. influenzae and S. pneumoniae are upper respiratory pathogens. These most often cause otitis media. Group A beta-hemolytic streptococcus is also an upper respiratory pathogen, but is not implicated in acute otitis media. S. aureus is commonly found on skin and E. coli is a bowel organism. Pasteurella is an infection associated with animal bites.
The mother of a 9-month-old infant calls the triage nurse with a concern that her child, who has a bad cold, might have an ear infection. The triage nurse elicits additional history. Which of the following can be identified from the healthhistory as a risk factor for the development of otitis media in children?
Show answer and rationale
Correct answer: C. Day care attendance
Day care attendance is recognized as a risk factor in otitis media because of increased exposure to bacterial pathogens and the likelihood that some of these pathogens may have developed resistance to antimicrobial therapy. Breastfeeding has been shown to decrease the incidence of otitis media in infants compared to bottle-feeding. Males less than school age are more at risk than females for the development of otitis media. There is currently no substantial evidence to support the link between the introduction of new foods and the development of otitis media, although some theories propose that allergies may play a role in the development of otitis media.
A 3-year-old boy is accompanied by his mother for follow-up of fluid in his middle ears. He had a bilateral ear infection 3�months ago and the fluid in his middle ears has persisted at all of his subsequent appointments. The nurse, based on an understanding of bilateral middle ear effusion, recognizes that this child should be
Show answer and rationale
Correct answer: A. screened for hearing loss.
A child who has had fluid in both middle ears for 3�months should have a hearing screen because there is increased potential for conductive hearing loss. Over time, conductive hearing loss could negatively affect the development of speech, language, and cognition. Otitis media with effusion can be a normal consequence of otitis media but should resolve by 3�months. There is no evidence to support limiting milk products to treat otitis media effusion.
A 5-year-old female has received tympanostomy tubes. The discharge nurse instructs the parent and child regarding tympanostomy tubes and their care. Which of the following would be included in the education plan?
Show answer and rationale
Correct answer: B. Earplugs are recommended for activities such as diving, submerging, bathing, and shampooing
Although swimming does not increase the risk of infection, diving, jumping, and submerging may. Bath water carries a higher risk of infection because it is contaminated, as is lake water. The use of earplugs is recommended for these activities. Soap reduces the surface tension of water, facilitating its entry into the tube, so earplugs are also recommended when shampooing. Most tympanostomy (PE) tubes fall out by 12�months and should be removed after 2�years. Children with tympanostomy tubes in place most often experience otitis when there is otorrhea from the PE tube.
A 12-year-old child has experienced repeated otitis externa. The child swims daily on a swim team and is unwilling to give that up. The nurse instructs the child and parents on methods to prevent further episodes. Which of the following is included in the plan?
Show answer and rationale
Correct answer: C. Instruct the parent and child to instill a 50% solution of vinegar and water into the ears after swimming
Instilling dilute vinegar and water into the ear of a child with otitis externa establishes an acidic environment, which is less conducive to bacterial growth. A cotton-tipped swab is not recommended for removal of water, because it may further damage the sensitive ear canal. Similarly, undiluted rubbing alcohol would be too harsh for the sensitive ear canal and may further damage tissue. The usual recommendation for water exposure is less than 1 hour at a time with a 1- to 2-hour interval between repeated exposures.
A 6-year-old child is scheduled for a tonsillectomy. The nurse is obtaining the preoperative history. Because of risks associatedwith this surgery, the nurse should report which of the following to the surgeon?
Show answer and rationale
Correct answer: A. There is a family history of bleeding tendencies
The operative site in a tonsillectomy is highly vascular, so family bleeding tendencies would require additional alertness for this potential problem in this client. It is ideal that the child does not have a concurrent upper respiratory infection, but this would not require notification of the surgeon. The child’s mouth should be assessed for loose teeth prior to surgery, so this notation is of little significance. Cleft palate is a contraindication to tonsillectomy.
The nurse is caring for a child following tonsillectomy. Which of the following observations should the nurse immediately report?
Show answer and rationale
Correct answer: A. The presence of blood trickling down the throat
The presence of blood trickling down the throat following a tonsillectomy is a sign of bleeding and should be communicated to the surgeon immediately. The dark brown blood is old and is commonly found on the teeth, in the nose, and in the emesis following tonsillectomy. It does not signify hemorrhage. Vomiting may be a normal sequela following surgery and does not need to be communicated to the surgeon. If, however, the vomitus contains bright red blood, then the surgeon should be notified immediately, as this is an indication of bleeding. A client complaint of a sore throat is an anticipated finding posttonsillectomy.
A 7-year-old child who has undergone tonsillectomy is alert, and the nurse is reviewing postoperative instructions. Which of the following should be included in the instructions?
Show answer and rationale
Correct answer: A. Coughing, clearing of throat, and blowing of the nose is discouraged
Coughing, clearing of the throat, and blowing the nose should be discouraged following a tonsillectomy. A soft diet, an oral intake of milk, and positioning the client prone or sidelying once alert may all stress the operative site and cause bleeding or hemorrhage. Typically, a cold, clear liquid diet is begun and advanced slowly as tolerated. The client may prefer an upright position once alert. The prone and sidelying positions are recommended until the client is alert. Milk products can be given later in the course, but should be avoided if they cause excessive clearing of the throat.
The mother of a child asks the nurse when the frontal sinuses in children develop. Which of the following is the appropriate response by the nurse? "The frontal sinuses are fully developed
Show answer and rationale
Correct answer: A. by age 7�years."
The frontal sinuses develop by age 7�years. The maxillary and ethmoid sinuses are present at birth, but they are very small. The sphenoid sinus does not develop fully until puberty.
A 9-year-old girl was diagnosed with strep throat and an antibiotic was prescribed. The mother asks the nurse when the child can return to school. Which of the following is the priority response by the nurse?
Show answer and rationale
Correct answer: A. "She may return after taking the antibiotic for a 24-hour period."
Twenty-four hours of antibiotic therapy decreases the number of colonies in respiratory secretions, thus lessening the infectious nature of strep throat. The child can return to school after 24�hours of antibiotic therapy when she is feeling better and is afebrile. This will likely be sooner than 1 week. The antibiotic is typically prescribed for 10 days, but this does not necessitate missing school for that period of time.
An adolescent experiences recurrent aphthous stomatitis. Which of the following should the nurse include in the instructions for a client with aphthous ulcers?
Show answer and rationale
Correct answer: D. Encourage fluids through a straw and soft diet while the ulcers are present
Aphthous stomatitis is canker sores. Eating a soft diet and using a straw will help avoid additional trauma and contact with painful lesions, allowing the child to eat. A soft-bristle toothbrush is recommended to avoid further trauma and irritation of the ulcers. Antiviral drugs such as acyclovir (Zovirax) are helpful to treat herpetic lesions but are not used in the treatment of aphthous ulcers. Aphthous ulcers typically last 4 to 12 days.
The nurse understands that viscous lidocaine is sometimes prescribed for clients with aphthous ulcers. The nurse should question a physician’s prescription for viscous lidocaine in which of the following clients?
Show answer and rationale
Correct answer: A. A toddler male with stomatitis
Viscous lidocaine can be prescribed for a client with aphthous ulcers. The client must be able to keep 1 teaspoon of the solution in the mouth for 2 to 3 minutes and then expectorate. The toddler patient would be unlikely to be able to do this. Adolescents and adults would likely be able to do this.
The nurse should assess for what related condition in a 4-month-old infant who has oral candidiasis?
Show answer and rationale
Correct answer: D. Diaper rash
Oral candidial lesions can spread to other body systems, including the gastrointestinal tract, and via poor hand washing by the caregiver. Concomitant monilial diaper rash is common. Although eczema, herpes simplex infection, and aphthous ulcers may be present, they are not directly related to the oral candidiasis.
A 2-month-old breast-fed infant has oral thrush. Which of the following is the most appropriate intervention to be included in the nurse’s plan of care?
Show answer and rationale
Correct answer: A. Instruct the mother on treatment of her nipples if she continues breastfeeding
The nipples of a mother who is breastfeeding an infant with oral thrush should be treated with a topical antifungal to avoid reinfection of the infant. Anbesol is not recommended in the treatment of oral candidiasis. Oral nystatin is the treatment of choice, but should be administered after feeding. Current guidelines recommend introduction of cereal at 6�months; adding cereal to the diet of a 2-month-old is inappropriate.
An 8-year-old boy will be undergoing skin allergy testing. The nurse should include which of the following precautions in the preparations?
Show answer and rationale
Correct answer: D. Evaluate for dermographism before beginning the testing
The client should be tested for dermographism before beginning skin allergy testing because dermographism may result in false-positive test results. Clients undergoing skin testing for allergy are at risk for an allergic reaction; those undergoing blood testing are unlikely to suffer allergic reactions. The physician should be on site for testing as there is potential for anaphylactic response and certainly for allergic reaction. Bleeding should be avoided during injection because this would create the potential for systemic allergen exposure and resultant anaphylaxis.
A 13-year-old female has been prescribed allergy injections every 3 to 4 weeks. The nurse instructs the child that following the injection, she
Show answer and rationale
Correct answer: C. must remain for observation for at least 20 minutes.
It is recommended that the client receiving allergy injections should remain for observation for 20 to 30 minutes following the injection to ensure that no delayed reaction occurs.
The registered nurse is preparing the nursing tasks for a pediatric eye, ear, nose, and throat disorder unit. Which of the following nursing tasks may be delegated to a licensed practical nurse?
Show answer and rationale
Correct answer: B. Perform a nasopharyngeal culture
A licensed practical nurse may perform a nasopharyngeal culture. Referring a child with strabismus to an ophthalmologist, instructing the parents of a child scheduled for a myringotomy, and monitoring the neurological status on a child with craniosynostosis are all nursing skills reserved for the registered nurse.
The nurse informs the parents of an infant that the primary difference between the chest of an infant and that of an adult is that the chest of an infant
Show answer and rationale
Correct answer: D. is rounded in shape.
An infant’s chest is almost circular in shape; in adults, the anterior-posterior diameter is less than the lateral diameter. The thoracic cavity for both infants and adults is cone-shaped and consists of bone, cartilage, and muscle.
A mother accompanies her 6-month-old male infant to the emergency room. She is concerned because the infant has not been feeding well. The infant has had a bad cold and cough, although the cough has subsided today. The nurse assessing the infant notes that the infant is very irritable and displays nasal flaring and intercostal retractions. Which of the following is the priority intervention for the nurse to take?
Show answer and rationale
Correct answer: D. Notify the physician that the infant needs to be seen quickly
Poor feeding, irritability, nasal flaring, and intercostal retractions are signs of altered respiratory function and respiratory distress in infants. It is important for the nurse to recognize these clinical manifestations in order to triage the infant, so that the physician sees this child before less ill clients. Infant feeding is likely decreased because the infant has air hunger and does not have the energy to feed. Suctioning the infant’s nose would likely increase hypoxia. Although it is important to acknowledge the mother’s concern regarding infant feeding, a more appropriate response is to have the physician see the infant as soon as possible.
While assessing a 13-year-old male following a motor vehicle accident, the nurse notes crepitus over the left lateral rib cage. Based on an understanding of crepitus, the nurse evaluates which of the following to cause the crepitus?
Show answer and rationale
Correct answer: C. Air escaped from the lungs and trapped in the subcutaneous tissue
Tactile fremitus is a palpable vibration over the chest wall that is produced by voice sounds. A pleural friction rub is auscultated as a grating sound. Remodeling in asthma does not cause crepitus.
The parents of a 10-year-old child ask the nurse what pulmonary function testing is. Which of the following is the most appropriate response by the nurse? "Pulmonary function testing
Show answer and rationale
Correct answer: D. is used to evaluate the severity of a respiratory disease."
Pulmonary function testing (PFT) is used to evaluate the severity of the disease. It is a noninvasive test. PFT cannot diagnose specific diseases because different diseases may have the same functional abnormalities. It is used to differentiate between restrictive and obstructive disease.
A 15-month-old infant is seen in a well-child exam. Because the infant’s family has recently emigrated from East Africa where tuberculosis (TB) is endemic, a Mantoux test is performed. No one in the infant’s family has currently or has in the past had tuberculosis. The mother brings the infant back to the clinic in 48 hours to have the Mantoux test read. According to this infant’s risk status and age, which is the smallest amount of induration that the nurse should consider a positive finding? An area of
Show answer and rationale
Correct answer: B. 10�mm induration.
For a child under the age of 4�years and born in an area of the world where tuberculosis is prevalent, a reading of 10�mm induration would be the lowest value that would be considered a positive finding in accordance with current clinical standards. Although a 15-mm and 20-mm induration would also be considered positive findings, given the younger age of 15�months, a positive reading would occur at 10�mm.
The nurse is caring for a 5-year-old child suspected of having tuberculosis. Which of the following is the preferred method of obtaining a sputum specimen for culture and smear from this child?
Show answer and rationale
Correct answer: A. Sputum collected by early morning gastric washings
Because young children are likely to swallow any sputum that is produced by cough, gastric lavage is a more effective method of collecting a sputum sample. It is the preferred method of collecting sputum for culture and smear from a child who is suspected of having tuberculosis. Endotracheal suctioning, unless intubated, would not be well tolerated, and thoracentesis is both invasive and impractical on a routine basis.
A mother reports that her 15-month-old child has had three colds in three months during the winter while attending day care. The mother inquires whether she should use an over-thecounter antihistamine for this child, because she suspects allergies must be the cause of the frequent colds. Which of the following is the nurse’s most appropriate intervention?
Show answer and rationale
Correct answer: C. Reassure the parent that frequent episodes of nasopharyngitis are common given the child’s risk factors
Nasopharyngitis occurs more frequently in infants and young children, especially in settings such as a day care center where many children interact in a small space. The most frequent transmission is by human hands, so good hand washing is essential to help prevent continuous colds. The fall and winter months are also prime times for colds. It is unlikely the�child is immunosuppressed based on the circumstances and clinical manifestations. The�nurse should not suggest that the child has asthma, because it is not in the scope of practice and the diagnosis is not supported by�the data collected. It would not be appropriate to make a recommendation concerning over-the-counter antihistamine therapy for a child this young. Antihistamines have also been found to be ineffective in treating nasopharyngitis.
A mother reports that her 4-month-old has a cold, but no fever. She reports noisy breathing at night and that the child’s nose is very congested. The nurse advises the mother to promote maximum ventilation during sleep. Which of the following instructions about positioning would be appropriate for the nurse to include in the instructions?
Show answer and rationale
Correct answer: A. Elevate the head of the crib 30 degrees
Appropriate positioning is a significant means of easing respiratory efforts in infants and small children. Elevation of the head of the crib or maintaining the infant’s head at 30 degrees will promote maximum lung expansion. Resting an infant’s head on a pillow is not recommended, because of the risk of sudden infant death syndrome. Positioning an infant at 90 degrees would actually compress the diaphragm and diminish respiratory function. Prone positioning of infants is generally not recommended, because of its correlation with sudden infant death syndrome. It should be noted that in the rare case that the infant is experiencing gastroesophageal reflux, positioning the infant prone may be permitted.
A 3-year-old child is brought to the emergency room at night with a harsh cough, hoarseness, and noisy breathing. Although the nurse’s initial assessment reveals a child who appears comfortable and whose respiratory status is within normal limits, a diagnosis of acute spasmodic laryngitis is made. Which of these instructions should the nurse include in the teaching plan?
Show answer and rationale
Correct answer: A. Clinical manifestations may resolve on exposure to cool night air
Exposure to cool night air or humidity may help relieve the spasm in acute spasmodic laryngitis. The parent should be advised that these attacks may be recurrent. The illness is usually not accompanied by fever. Stimulation may aggravate the dyspnea.
Which of the following should the nurse include in a plan of care for a 5-year-old child admitted to the hospital with the diagnosis of epiglottitis?
Show answer and rationale
Correct answer: D. Encourage the child to assume a tripod position
Epiglottitis, also referred to as croup syndrome, is a life-threatening bacterial infection that can lead to a complete airway obstruction. Because of difficulty breathing and swallowing, the child is likely to assume a tripod position. This is characterized by the child sitting upright and leaning forward with chin thrust out, tongue protruding, and mouth open to facilitate breathing and swallowing. A throat culture should not be done, as this could cause additional or complete obstruction. Examination of the throat should only occur when emergency tracheostomy or intubation is possible. The onset of epiglottitis is usually abrupt and is more likely preceded by a sore throat than by cold manifestations. It is most common in children between the ages of 2 and 7�years. Fluids, antibiotics, and supportive care are included in the treatment plan.
A mother calls the medical information line and reports that her 6-year-old child has awakened with a complaint of sore throat and pain on swallowing. She reports that the child was fine when going to bed. The child has a fever of 39.2�C, or 102.5�F, orally and is restless and appears quite sick. Which of the following questions is a priority for the nurse to ask to triage this client?
Show answer and rationale
Correct answer: A. "Has the child been drooling?"
Clinical manifestations of a sore throat, difficulty swallowing, restlessness, and temperature of 39.2�C, or 102.5�F, orally is suggestive of epiglottitis, which is a medical emergency. Confirming that the child is drooling would be additional data to support the nurse’s suspicions and assist to direct the parent and child to an emergency department for evaluation and treatment. Although asking about strep throat, administration of an antipyretic, and immunizations may be appropriate questions for any parent of a child, the priority question would be to inquire about drooling.
A child in the emergency room is suspected of having epiglottitis. Which of the following is the priority to include in this client’s plan of�care?
Show answer and rationale
Correct answer: C. Ensure that the child has a patent airway
Epiglottitis, or croup syndrome, is a bacterial infection that may lead to a complete airway obstruction. It should be managed in the same way as acute respiratory distress, with maintenance of the airway being the priority. Establishing IV access and assisting with x-ray will also be done, but only after the airway has been ensured and trained personnel are available. The nurse should not perform any procedures without additional medical team support. Communicating to the parents is important, but only after the client is stabilized.
A 4-year-old child with epiglottitis is being transferred via ambulance to the hospital. The parents and child are very fearful. The mother asks if her child can sit in her lap for transport. What is the nurse’s best response?
Show answer and rationale
Correct answer: B. "Letting your child ride on your lap may reduce your child’s stress."
Being allowed to sit on a parent’s lap may actually decrease the child’s (and parent’s) stress and facilitate easier breathing. Such a request would need to be approved by the physician and the ambulance personnel. Isolating the child from the parents would very likely increase the child’s stress and consequently the respiratory dysfunction. This would be counterproductive. Sedation would be inappropriate in this situation, as it would further compromise respiratory effort.
The father of a child with laryngotracheobronchitis asks the nurse what it is. Which of the following statements by the nurse best describes laryngotracheobronchitis?
Show answer and rationale
Correct answer: B. "It is a viral illness that results in swelling around the level of the larynx characterized by a barking cough and hoarseness."
Laryngotracheobronchitis (croup) is a viral illness that results in swelling around the level of the larynx characterized by a barking cough and hoarseness. A reactive airway disease characterized by wheezing and cough is a description of asthma. A viral illness that results in inflammation of the small airways and production of thick mucus is a description of bronchiolitis. A bacterial illness that results in serious supraglottic inflammation is a description of epiglottitis.
A child with a brassy cough, mild fever, and hoarseness is seen in the emergency department and diagnosed with croup. The physician orders discharge to home with management to include cool-temperature therapy. The nurse preparing discharge teaching notices that the child has developed continuous respiratory stridor. Which of the following is the priority nursing intervention?
Show answer and rationale
Correct answer: C. Notify the physician of the child’s status immediately
Stridor is a high-pitched sound produced by an obstruction of the trachea or larynx that can be heard during inspiration or expiration. Stridor even at rest signifies progression of the croup and requires medical management. The physician should be notified immediately. It would be inappropriate to discharge the client in view of the change in status without notifying the physician. Instructing the parents on cool-temperature therapy is an appropriate intervention but not the priority.
The nurse administers which of the following vaccines to help prevent the development of epiglottitis?
Show answer and rationale
Correct answer: A. Haemophilus influenzae vaccine (HIB)
Haemophilus influenzae is the most common causative organism of epiglottitis. The H. influenzae vaccine may help prevent it. Diphtheria/tetanus/acellular pertussis (DTaP) immunizes against diphtheria, tetanus, and pertussis. Varivax immunizes against varicella (chickenpox), and Prevnar immunizes against streptococcal pneumonia and to a lesser degree ear infections caused by Streptococcus pneumoniae.
The nurse is caring for a 5-year-old child diagnosed with bronchitis who is otherwise in good health. The child’s mother verbalizes to the nurse that she is very upset that the physician did not prescribe antibiotics. The nurse’s response would be based on the understanding that bronchitis is
Show answer and rationale
Correct answer: A. usually viral in a child under 5�years and not affected by antibiotic therapy.
Laryngotracheobronchitis (croup) is usually caused by a virus, especially in young children. Antibiotics are ineffective against viral illnesses. It would be appropriate for the nurse to explain this rationale to the parent as part of client and family education. Bronchitis is not treated with antihistamines. Cough suppressants should be used with caution as they may make the child drowsy and may also impede the clearance of secretions. The issue in antibiotic resistance is to treat with an adequate dose of an antibiotic that is active against the offending pathogen, not whether or not to treat.
Which of the following infection control measures is the priority for the nurse to implement in the care provided to a 5-month-old infant admitted to the hospital with respiratory syncytial virus (RSV) bronchiolitis?
Show answer and rationale
Correct answer: B. Hand washing is required by all personnel and visitors having contact with the infant
Bronchiolitis is a viral infection causing inflammation of the bronchioles and production of thick mucus that occludes the bronchiole tubes and small airways, impeding expiration. Of the infection control measures implemented, consistent hand washing and not touching the nasal mucosa or conjunctivae have been shown to be most important. Wearing masks and gowns has not been shown to be of added benefit, although the gowns may help reduce the risk of fomite spread. Infants with RSV may be in rooms with children with similar diagnosis or isolated in private rooms, dependent on hospital policy. The advisability of limiting of visitors and staff in an effort to lessen the spread of infection is being studied.
The parents of a 5-month-old infant who has bronchiolitis ask the nurse what changes occur to the lung during the illness. The nurse informs these parents that which of the following lung changes occur?
Show answer and rationale
Correct answer: C. Emphysema
In bronchiolitis, the bronchioles and small airways become occluded due to inflammation and thick mucus. Air becomes trapped behind the occlusions, where it leads to progressive overinflation of the lungs called emphysema. While some infants may manifest asthmalike manifestations, this does not reflect the usual progression of bronchiolitis. Atelectasis is a collapse of the lung and is not a normal development in bronchiolitis. Crepitus is a crackling sound on palpation caused by the escape of air into the subcutaneous tissue and is also not common in bronchiolitis.
Which of the following methods should the nurse use to collect a respiratory syncytial virus (RSV) culture that has been ordered on a 6-month-old infant?
Show answer and rationale
Correct answer: B. Perform a nasal washing
The nasal washing is identified as the method of choice for collecting the nasal specimen for respiratory syncytial virus (RSV). Although sometimes used, a nasopharyngeal swab is not as effective a collection technique. Venipuncture and gastric lavage are not used to obtain specimens for RSV determination.
The nurse screens which of the following pediatric age groups for atypical pneumonia caused by mycoplasma?
Show answer and rationale
Correct answer: A. School age
Mycoplasma pneumoniae is the most common causative agent of pneumonia in school-age children between the ages of 5 and 12�years. Viral pneumonia is the most common pneumonia overall and is seen in all age groups. Bacterial pneumonias are more prevalent in children under age 5�years.
The nurse is teaching a class on sudden infant death syndrome to parents. Which of the following should the nurse include in the class?
Show answer and rationale
Correct answer: A. Being a low-birth-weight male infant increases the risk
Sudden infant death syndrome is the unexpected death of an apparently healthy infant under the age of 1�year. Peak incidence is between 2 and 4�months. It occurs more frequently between the ages of 2 and 4�months and in the winter months. Low-birth-weight male infants are at a greater risk than are females. There is no diagnostic test for sudden infant death syndrome.
The clinical assignments on a pediatric respiratory unit have been made for the day. Which of the following assignments should be questioned?
Show answer and rationale
Correct answer: C. A licensed practical nurse is assigned to teach a class to parents on sudden infant death syndrome
Unlicensed assistive personnel may help a child walk and eat. A licensed practical nurse may administer a bronchodilator to a child with asthma. It is inappropriate to assign a licensed practical nurse to teach a class on sudden infant death syndrome. A registered nurse should be given responsibility for teaching such a class.
The nurse took respiratory rates on the following four pediatric clients. Which of the following clients should the nurse report as having an abnormal respiratory rate?
Show answer and rationale
Correct answer: B. An 18-year-old who has respirations of 25�breaths per minute
The respiratory rate of an infant from birth to 6�months is 30 to 50 breaths per minute. Children between 6�months and 2�years of age would have respirations from 20 to 30 breaths per minute. Children between 3 and 10�years of age have respirations between 20 and 28�breaths per minute. The respiratory rate of�children between 10 and 14�years of age is between 16 and 20 breaths per minute. The respiratory rate of children between16 and 18�years of age would be between 12 and 20 breaths per minute. An 18-year-old who has respirations of 25 breaths per minute is experiencing some degree of respiratory distress and that finding should be reported.
The nurse is caring for a child suspected of having bacterial tracheitis. Which of the following is the primary clinical manifestation that the nurse assesses supporting this diagnosis?
Show answer and rationale
Correct answer: B. Thick purulent tracheal secretions
Bacterial tracheitis is a bacterial infection involving the mucosa of the upper trachea. Although fever, brassy cough, and inspiratory stridor are all clinical manifestations of bacterial tracheitis, the hallmark manifestation diagnostic of the condition is thick, purulent tracheal secretions. If left untreated, these secretions may result in airway obstruction or even respiratory arrest.
The nurse is reviewing the chart of a child with coarctation of the aorta. Which of the following findings would the nurse anticipate?
Show answer and rationale
Correct answer: C. Cerebral hypertension
Coarctation of the aorta is a stenosis most commonly located within the thoracic aorta that increases systemic resistance at the site of the coarctation. This causes an increase in pressure proximal to the coarctation, causing hypertension in the cerebral arteries. Arteries distal to the coarctation have reduced pressure, causing lower extremity hypotension.
The nurse is planning care for a 2-year-old child immediately following cardiac catheterization. Which of these activities should have the highest priority?
Show answer and rationale
Correct answer: D. Apply direct pressure to the catheterization site for at least 15 minutes
Direct pressure on the site for 15 minutes and frequent monitoring of the occlusive pressure dressing will decrease the risk of complications from hematoma or hemorrhage following cardiac catheterization. The dressing should not be changed immediately postprocedure, as disruption of the clot may cause life-threatening hemorrhage. Monitoring the heart rate for 1�minute during vital signs and starting oral fluids are appropriate actions in postoperative care, but are of lower priority in the assessment and care of the child immediately post-op.
The nurse includes which of the following in a discharge teaching plan for parents of a child who has just undergone a cardiac catheterization for a cardiac defect?
Show answer and rationale
Correct answer: C. Administer antibiotics for two weeks
After a cardiac catheterization, the dressing will be removed before discharge and stitches are not necessary for this procedure. The postprocedure diet is the child’s usual diet, and home cardiac monitors are not used after cardiac catheterization. Antibiotics are used for children with heart defects prophylactically to minimize the risk of infection.
The nurse asks the mother of a child suspected of having a congenital heart defect about eating patterns and activities. Based on an understanding of this child’s condition, which of the following should the nurse consider before recommending a plan of care?
Show answer and rationale
Correct answer: A. Poor feeding and activity intolerance are common in children with congenital heart disease
Poor appetite and feeding patterns and activity intolerance are common to many congenital heart diseases. This is the primary consideration for the nurse before recommending the child’s plan of care.
The nurse is evaluating heart sounds in four children. Which of the following heart sounds found in a 4-year-old child does the nurse report as pathologic?
Show answer and rationale
Correct answer: D. S4
The S1 and S2 are normal heart sounds at the beginning (closure of AV valves) and end (closure of semilunar valves) of ventricular systole. The S3 sound occurs early in diastole and is considered normal in children and young adults, but is a sound of cardiac disease in older adults. S4 is a rare sound and not heard in a normal heart.
A 5-year-old child is scheduled for an echocardiogram. She asks the nurse if the test will hurt. Which of the following is the nurse’s best response?
Show answer and rationale
Correct answer: A. "There will be a jelly that will feel cool, but it won’t hurt."
An echocardiogram is noninvasive and painless. The child needs to be reassured.
The nurse is caring for a child with tetralogy of Fallot who experiences an episode of acute cyanosis. Which of the following is the primary clinical manifestation the nurse will assess?
Show answer and rationale
Correct answer: A. Anxiousness and irritability
Tetralogy of Fallot is comprised of a ventral septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. During a cyanotic spell, pulse and respiratory rates increase to compensate for decreased oxygen levels. Anxiety and irritability are the most common manifestation in children with hypoxic spells. Loss of consciousness is more likely to be seen in states of severe heart failure.
Which of the following should be included in the discharge teaching the nurse is preparing for the parents of a child with tetralogy of Fallot?
Show answer and rationale
Correct answer: D. Use of the knee-chest position for cyanotic spells
Tetralogy of Fallot is comprised of a ventral septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. The use of the knee-chest position is effective in decreasing cardiac workload. Complete bed rest is inappropriate; as much normal activity as can be tolerated is encouraged. Signs of infection and suctioning are not a part of the care for a child with tetralogy of Fallot.
The nurse is caring for a child with Kawasaki disease. Which of the following would indicate to the nurse that the client’s condition is deteriorating?
Show answer and rationale
Correct answer: A. Arrhythmias
Kawasaki disease is a multisystem vasculitis that affects the coronary arteries. Hypotension and strep throat are not manifestations seen in Kawasaki disease. Cardiac complications are the most serious and contribute to morbidity and mortality. Tachycardia, a gallop rhythm, and congestive heart failure may occur.
The nurse is caring for a child with a possible diagnosis of rheumatic fever. Which of the following assessment findings does the nurse evaluate as a diagnostic criterion?
Show answer and rationale
Correct answer: D. Elevation of antistreptolysin (ASO) levels
Streptococcal infection precedes the development of rheumatic fever by approximately 2 weeks. Elevation of antistreptolysin (ASO) levels indicates a recent strep infection.
When preparing discharge teaching for a family of a child recovering from rheumatic fever, the nurse’s priority instruction is
Show answer and rationale
Correct answer: D. the child needs to take prophylactic antibiotics to prevent endocarditis.
Rheumatic fever is thought to be an autoimmune disorder related to group A streptococcal infection. Future streptococcal infection and the risk for endocarditis can be prevented with prophylactic antibiotic administration. Resuming school activities and informing the school nurse about the illness may be appropriate interventions, but they are of lower priority. Poor appetite and growth do not generally occur with rheumatic fever unless the child already has experienced significant heart damage.
Which of the following should the nurse include in the discharge instructions for an infant with an atrial septal defect?
Show answer and rationale
Correct answer: A. Cardiopulmonary resuscitation
An atrial septal defect is an abnormal connection between the right and left atria. Children with any heart defect are at a higher risk for heart failure. Instruction in cardiopulmonary resuscitation (CPR) increases parental confidence and prepares them to handle an emergency.
A child’s mother asks the nurse how her child got hypertension and what it means. In explaining hypertension in children, the nurse would most appropriately respond that in children, hypertension "is
Show answer and rationale
Correct answer: A. generally related to another disease process."
Secondary hypertension is much more common in children than primary hypertension. It is usually a manifestation of another disease process. Hypertension in children is of concern and treatable. The association with cholesterol is not applicable.
Which of the following should the nurse include in the preoperative teaching for the parents of a child scheduled for cardiac surgery?
Show answer and rationale
Correct answer: B. Concepts of pain management
It is appropriate to instruct the parents of a child scheduled for cardiac surgery in the concepts of pain management. Toys from home can be comforting to a hospitalized child as can sibling visits. Siblings are also comforted by seeing the child in person. Although a tour of the intensive care unit is appropriate, the tour of general pediatrics can come later as necessary.
A nurse caring for a young child with a newly diagnosed atrial septal defect would
Show answer and rationale
Correct answer: D. prepare the child for echocardiogram.
An atrial septal defect is an abnormality between the left and right atria. A chest x-ray and an echocardiogram are generally performed to demonstrate the increase in the heart size and location and size of the defect. Cyanotic spells are generally not seen in atrial septal defects. Cyanosis itself is rare unless the defect in the septum is large enough to allow significant mixing of oxygenated and unoxygenated blood.
To reduce cardiac workload, the nurse should implement which of the following nursing interventions for a child in heart failure?
Show answer and rationale
Correct answer: A. Provide a quiet environment
Placing a child with a cardiac condition in a Trendelenburg position and encouraging fluids would actually increase cardiac workload. The preferred method of feeding to reduce cardiac workload is to feed five to six small meals a day. A quiet environment reduces stress and anxiety, resulting in a reduced cardiac workload.
The parents of a 3-year-old child with tetralogy of Fallot tell the nurse that their child frequently squats during play. Based on an understanding of tetralogy of Fallot, the nurse recognizes that this is
Show answer and rationale
Correct answer: D. a compensatory mechanism.
Tetralogy of Fallot is comprised of a ventral septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. Squatting helps the child’s circulatory system compensate for episodes of hypoxemia, especially during active periods.
The nurse caring for an infant with patent ductus arteriosus informs the parents that corrective surgery will prevent
Show answer and rationale
Correct answer: B. pulmonary vascular congestion.
The ductus arteriosus is a direct connection between the main pulmonary artery and the aorta. When the connection remains open several weeks after birth in a full-term infant, it is a patent ductus arteriosus. Patent ductus arteriosus causes an increase in blood flow in the reverse of what it was in fetal life as systemic pressure increases relative to pulmonary pressures. This causes an increase in pulmonary flow through the pulmonary artery. Pulmonary vascular congestion is the risk in this case.
Which of the following is the nurse’s priority intervention in a child with pulmonary stenosis?
Show answer and rationale
Correct answer: B. Monitor for indications of congestive heart failure
Pulmonary stenosis is a narrowing of the pulmonary valve and obstruction of the blood flow from the right ventricle to the lungs. Monitoring the child for congestive heart failure is the priority as it is potentially life threatening. Provision of sensory preparation for the x-ray is also important but not as significant as monitoring for congestive heart failure (CHF). Educating the parents about home medications and discussing the child’s nutritional and developmental needs are appropriate interventions later in the hospitalization.
A child with an atrioventricular canal has been experiencing difficulty breathing and productive cough for 3 days. On admission, the nurse notes nasal flaring and retractions. At this point the nurse’s priority action is to
Show answer and rationale
Correct answer: A. administer oxygen via mask.
An atrioventricular canal is a defect that allows blood to flow among all four chambers. An atrial septal defect is continuous with a ventricular septal defect along the septum, also affecting both AV valves (mitral and tricuspid), creating essentially one large chamber. Blood flow direction depends on the child’s peripheral resistance and pulmonary resistance as well as ventricular pressures. This defect is seen in Down syndrome. This client is experiencing labored breathing and requires oxygen immediately. This can be applied quickly before calling the physician. Reassuring the parents and obtaining a weight are also important interventions, but immediate oxygen could reduce the difficulty of breathing for this child and help stabilize the condition.
The nurse is assessing an infant who has been transferred from another facility for examination of possible cardiac anomalies. The child has congestive heart failure, is severely cyanotic, and is on mechanical ventilation. The chest x-ray shows an abnormally large right ventricle and a very small left ventricle. The nurse recognizes that this is most likely
Show answer and rationale
Correct answer: A. hypoplastic left heart syndrome.
Hypoplastic left heart syndrome is characterized by a lack of development of the left ventricle secondary to mitral valve atresia or aortic atresia. The result is a small hypoplastic left ventricle not capable of cardiac function.
The registered nurse is preparing clinical assignments for a pediatric unit. Which of the following nursing assignments may be delegated to a licensed practical nurse?
Show answer and rationale
Correct answer: A. Assist a child with tetralogy of Fallot to a knee-chest position during an acute hypoxic spell
Nursing assignments involving skills such as instructing, informing, or assessing should be performed only by a registered nurse. A licensed practical nurse may assist a child with tetralogy of Fallot to a knee-chest position during an acute hypoxic spell because the initial instruction has taken place.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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