NCLEX Practice Questions — Set 4
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
Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
Show answer and rationale
Correct answer: A. Enfamil formula ad lib.
an infant with a congenital heart defect frequently requires formula with extra calories per ounce. Regular Enfamil formula would not provide sufficient calories.
A nurse would be most correct in withholding digoxin (Lanoxin) prescribed to an infant if the heart rate falls below which parameter?
Show answer and rationale
Correct answer: D. Below 100 beats per minute.
digoxin (Lanoxin) should be withheld if the heart rate of the infant falls below 90 to 110 beats per minute (bpm). If digoxin (Lanoxin) is given when the infant’s heart rate is 100, the resulting cardiac output may not be adequate.
A hospitalized child is experiencing sickle cell vasoocclusive crisis. The child is currently receiving an intravenous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities per physician orders. During the midday assessment, the child reports no pain. Which action should a nurse take?
Show answer and rationale
Correct answer: B. Continue to apply warm compresses per physician order.
since the child is currently receiving a fluid bolus, which may be providing temporary improvement of pain symptoms. Ongoing application of warm compresses will continue to promote circulation in the extremities, thereby preventing pain. Once the fluid bolus is completed, the nurse should reassess the child’s pain and circulation.
What should be the expected weight of an infant at 12 months of age whose birth weight was 3600 grams?
Show answer and rationale
Correct answer: A. 11 kilograms.
an infant is expected to triple its birth weight in the first year of life; therefore, 11 kilograms (11,000 grams) is the best answer of the options given.
An infant in a newborn nursery is identified as having phenylketonuria (PKU). What is the best initial source of nutrients for an infant with this diagnosis?
Show answer and rationale
Correct answer: A. Maternal breast milk.
the child with PKU is missing the enzyme needed to digest the amino acid phenylalanine. Maternal breast milk has many beneficial properties and it contains low levels of phenylalanine. Therefore, breast milk should be given until laboratory findings demonstrate the child is not tolerating the breast milk.
In assessing the reflexes of a 15-month-old child, which finding would indicate that the child is experiencing normal development?
Show answer and rationale
Correct answer: A. Positive patellar reflex.
a positive patellar reflex is part of a normal assessment. The reflex is obtained when the practitioner strikes the patellar tendon, causing the leg to kick.
A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the nurse’s first priority when caring for this child?
Show answer and rationale
Correct answer: C. Obtaining a daily weight.
because of primary concern in the child with glomerulonephritis is the monitoring of fluid balance. The nurse should obtain a weight for this child at the same time and on the same scale daily to monitor for changes.
In developing a plan of care for a hospitalized preschooler, a nurse recognizes that it is most essential to consider:
Show answer and rationale
Correct answer: B. That the child may believe the hospitalization is a punishment.
preschoolers may perceive hospitalization as a punishment. The nurse should create a plan of care that reassures the child and helps the child understand the reasons for hospitalization.
A nurse assesses a child who is 12 hours status post- tonsillectomy and adenoidectomy. The child reports feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in the emesis basin. Which action should the nurse take first?
Show answer and rationale
Correct answer: D. Report the findings to the physician.
the appearance of moderate red-tinged vomitus could indicate hemorrhage in the surgical area. The physician should be notified immediately of this potentially harmful complication.
The parents of a 2-year-old child ask a nurse how to best assist the child to accomplish developmental tasks at this age. What is the best response by the nurse?
Show answer and rationale
Correct answer: D. "Ask grandparents and other child care providers to follow your home schedule as much as possible."
toddlers prefer predictable schedules and routines. The child will feel more comfortable if the home schedule is implemented when away from the parents.
An infant is hospitalized following a febrile seizure. When a nurse teaches the infant’s family about the prevention of future seizures, what would be the nurse’s best recommendation?
Show answer and rationale
Correct answer: D. Administer antipyretics around the clock the next time the child has a fever.
febrile seizures are thought to occur when a child who is ill has a sudden high fever. To prevent this situation, the parents should be instructed to administer an antipyretic around the clock during the next febrile illness.
A toddler with Kawasaki disease is being evaluated by a primary care clinic nurse 1 week following discharge. The nurse understands that it is a priority to instruct the parents to contact the clinic immediately if the child:
Show answer and rationale
Correct answer: D. Is exposed to someone with chickenpox.
children with Kawasaki disease are placed on aspirin therapy, so exposure to chickenpox puts the child at risk for Reye syndrome.
A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first?
Show answer and rationale
Correct answer: B. Whether the child is able to speak in full sentences.
the nurse should first assess the child’s airway to determine the severity of respiratory symptoms. One way to assess shortness of breath is to determine whether the child speaks in full sentences, short phrases, or barely at all.
A child is seen in an emergency department following the ingestion of lighter fluid. Which nursing action is of the highest priority at this time?
Show answer and rationale
Correct answer: A. Assess the respiratory system.
when a child ingests a hydrocarbon such as lighter fluid, there is an immediate danger of aspiration. Therefore, the nurse’s first priority is to assess the lungs.
A nurse prepares to administer a chelating agent to a child with lead poisoning. Which laboratory tests should be obtained prior to the administration of this agent?
Show answer and rationale
Correct answer: D. BUN and creatinine.
the chelating agent binds with lead and is excreted by the kidneys; therefore, normal kidney function should be established beforehand; blood urea nitrogen (BUN) and creatinine provide the best evidence of function.
A nurse is caring for a child with meningococcemia who is on a ventilator. This morning, the nurse finds the child’s mother sitting at the bedside, crying. The mother tells the nurse, "I thought it was the flu. This is my fault because I should have come to the hospital earlier." What is the best action by the nurse in response to the mother’s statements?
Show answer and rationale
Correct answer: C. Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now.
the mother’s statement expresses guilt feelings about the child’s condition. A nurse needs to validate that the mother did seek treatment appropriately, and assist the mother to focus on what is happening now to help her child recover.
An infant is admitted for probable pyloric stenosis. A physician orders IV fluids and makes the infant NPO pending a surgical consult. The infant is crying vigorously and the parents express frustration that they cannot feed their baby even though the surgery is not yet definite. Which is the best action for the nurse to take now?
Show answer and rationale
Correct answer: C. Explain to the parents that feeding an infant with pyloric stenosis can lead to electrolyte imbalances from possible vomiting.
the best action for the nurse is to help the parents understand that the NPO status is to avoid vomiting. This message should be delivered while expressing empathy for the situation.
A 1-day-old infant, born at 39 weeks’ gestation, weighs 4 pounds, 7 ounces at birth. A pediatrician diagnoses the neonate with intrauterine growth restriction (IGR). An RN observes the newborn to be irritable, difficult to console, restless, fist-sucking, and demonstrating a highpitched, shrill cry. Based on these assessment data, the RN should:
Show answer and rationale
Correct answer: A. Tightly swaddle the infant in a flexed position.
tightly swaddling the baby promotes the infant’s comfort and security and decreases the stimulation that may contribute to the infant’s irritability.
A nurse performs a scoliosis screening at a local school. Which assessment finding by the nurse would least likely result in a scoliosis referral?
Show answer and rationale
Correct answer: A. Rounded shoulders noted when the child is standing erect.
the nurse is least likely to refer a child for scoliosis follow-up based on an assessment finding of rounded shoulders. This finding may simply reflect the child’s poor posture or in severe cases may indicate the condition of kyphosis, not scoliosis.
Which conditions in children and/or adolescents should a nurse identify as being associated with metabolic alkalosis? Select all that apply.
Show answer and rationale
Correct answer: D. Pyloric stenosis.
children with pyloric stenosis experience loss of stomach acid from excessive vomiting.
A child is admitted for treatment of lead poisoning. A nurse recognizes that the priority nursing diagnosis for this child is:
Show answer and rationale
Correct answer: B. Alteration in neurologic functioning.
the priority nursing diagnosis for this child is alteration in neurologic functioning due to the effects of lead on the central nervous system.
A newborn arrives in a neonatal intensive care unit with a myelomeningocele. A physician writes orders to keep the infant in the prone position. A nurse should know that the most important rationale behind this order is to:
Show answer and rationale
Correct answer: A. Prevent trauma to the meningeal sac.
the most important rationale for the prone position is to prevent damage to the meningeal sac, which could result in damage to the nerves and infection.
A child, hospitalized with nephrotic syndrome, has been receiving corticosteroids for a week. What should the nurse recognize as early evidence that the child is responding well to treatment?
Show answer and rationale
Correct answer: A. Increased urinary output.
the earliest sign that a child with nephrotic syndrome is improving is an increase in urine output.
A nurse is performing discharge teaching with the parents of a preschooler diagnosed with cystic fibrosis. What part of the teaching plan will best assist the parents to prevent future pulmonary infections in this child?
Show answer and rationale
Correct answer: A. Emphasizing the need for regular and consistent chest physiotherapy.
chest physiotherapy (CPT) is essential to help loosen sticky respiratory secretions and facilitate sputum removal in the child with cystic fibrosis. Failure to implement this treatment would create a ready environment for pulmonary infection.
The mother of a child asks a clinic nurse how to safetyproof the home. What should the nurse recognize as the most effective means to prevent accidental poisoning?
Show answer and rationale
Correct answer: A. Scan the home from the child’s eye level and remove accessible toxins.
the parents should bend down and view the home from the child’s eye level to better examine potential access to poisonous substances. This includes checking all storage areas inside and outside the home that are easily accessible and those that may be reached by children when climbing.
A nurse visits the home of a toddler. With what aspect of the home environment would the nurse be most concerned?
Show answer and rationale
Correct answer: C. Cooking pot handle turned toward the front of the stove.
toddlers like to reach for objects. Having pot handles turned toward the front of the stove creates the potential for the child to pull the pot and its contents onto the child, causing a severe burn injury. The parents should be instructed to turn handles toward the back of the stove and consider placing a safety guard at the front of the stove.
An infant is admitted to a pediatric unit with labored breathing and moderate amounts of thick nasal secretions. What nursing intervention is most likely to improve the infant’s oxygenation?
Show answer and rationale
Correct answer: B. Frequent suctioning of the nares with a nasal olive.
infants are obligatory nose breathers. A nurse should attempt to keep nasal passages open through frequent suctioning with a nasal olive.
A client is attending a newborn discharge class and asks a nurse about the bump on the infant’s head. Upon assessment, the neonate has a large, diffuse swelling on the left occiput that crosses the sagittal suture line. The nurse should explain to the mother that: Select all that apply.
Show answer and rationale
Correct answer: B. It is edematous swelling that overlies the periosteum.
caput succedaneum is an edematous swelling that overlies the periosteum.
A child with status post-Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first?
Show answer and rationale
Correct answer: D. Assess patency of the urinary catheter.
the child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord surgery. Since bladder distention can lead to this problem, the nurse should first assess the urinary catheter for obstruction or malfunction.
What assessment findings should a nurse expect in a child with acute post-streptococcal glomerulonephritis? Select all that apply.
Show answer and rationale
Correct answer: D. Severe hematuria.
child with acute glomerulonephritis has large amounts of red blood cells in the urine due to ruptured glomerular capillaries.
In doing a child’s admission assessment, which signs and symptoms should a nurse recognize as most likely related to rheumatic fever?
Show answer and rationale
Correct answer: A. Arthralgia and muscle weakness.
symptoms of rheumatic fever include muscle weakness and arthralgia.
When preparing an intramuscular injection for a 1-week-old infant, which needle would be the most appropriate for the nurse to select?
Show answer and rationale
Correct answer: D. 25 G, 5 /8 inch.
the most appropriate needle to select for use in administering IM injection to a 1-week-old infant would be a 25 gauge, 5 /8 inch long.
A young child diagnosed with iron-deficiency anemia is prescribed a liquid iron supplement. A nurse provides the parents with instructions on administration and should be certain to advise them that:
Show answer and rationale
Correct answer: C. The medication can be mixed with a small amount of fruit juice.
since iron is best absorbed in the presence of vitamin C. The liquid iron supplement may be mixed with fruit juices such as orange juice to make the medication more palatable while also increasing the absorption.
A child is receiving chemotherapy for the treatment of osteosarcoma. Which morning laboratory result must a nurse report immediately to the physician?
Show answer and rationale
Correct answer: D. Urine dipstick positive for heme.
a positive urine dipstick for the presence of red blood cells could indicate hemorrhagic cystitis, a complication of chemotherapy agents, including cyclophosphamide and ifosfamide. This finding should be communicated immediately to the physician.
Which statement made by the mother of a child with cystic fibrosis should indicate to a nurse that the mother is in need of further teaching regarding the administration of pancreatic enzymes?
Show answer and rationale
Correct answer: A. "I’ll crush the capsules and mix with my child’s food."
this statement by the mother indicates more teaching is needed, since crushing the capsule would destroy the enteric coating on the enzyme beads, leading to their destruction in the acid environment of the stomach.
A nurse is working with a nursing student in the care of a young child status post-appendectomy. The student checks the current order of IV gentamicin and discovers the ordered dose is above the safe dose range based on the child’s weight. What should be the nurse’s first action?
Show answer and rationale
Correct answer: A. Check the child’s recent lab work.
the nurse should first check the child’s recent laboratory work to see if a gentamicin level has been done. The physician may have increased the dose of IV gentamicin above the safe dose range if the child’s gentamicin level fell below that which is effective. The safe dose range is the starting point for this medication, but the dose is then increased or decreased to achieve therapeutic blood levels.
A child with type 1 diabetes is being prepared for discharge from a hospital. What should a nurse include as part of the teaching regarding diabetes care?
Show answer and rationale
Correct answer: A. Insulin dosage may need to be decreased during sports activities.
since the body becomes more sensitive to insulin with physical activity, and it may be necessary to reduce the child’s insulin dosage with sports participation.
An LVN/LPN from an orthopedic unit is floated to a child health unit. In creating assignments, which child should the charge nurse avoid assigning to the LVN/LPN?
Show answer and rationale
Correct answer: A. A teenager receiving chemotherapy for osteosarcoma.
the child with osteosarcoma is receiving chemotherapy, which requires continuous monitoring for complications. This child would not be an appropriate client for the LVN/LPN due to the need for frequent assessment by a registered nurse.
A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse?
Show answer and rationale
Correct answer: C. Negative Babinski reflex.
the newborn should have a positive Babinski, or plantar, reflex. This reflex occurs when the toes extend in response to the stroking of the sole of the foot. A negative finding should occur in older infants and adults and is noted when the toes demonstrate a flexor response.
The parent of a young child phones an advice nurse to report that the child is ill. The child has a reddish pinpoint rash most concentrated in the axilla and groin areas, a high fever, flushed cheeks, and abdominal pain. The parent also reports that the child’s tongue is dark red with white spots. A nurse should recognize these symptoms as indicative of which infection?
Show answer and rationale
Correct answer: D. Scarlet fever.
these symptoms are classic for scarlet fever. The child develops a high fever, abdominal pain, flushed cheeks, and strawberry tongue, as well as a generalized pinpoint red rash that is more concentrated in the axillae and groin.
An 80-year-old client is being discharged home after having surgery to d�bride a chronic venous ulcer on the right ankle. Which referral is most appropriate for DH, the charge nurse, to make?
Show answer and rationale
Correct answer: C. Home health.
The home health nurse is an appropriate referral for this client. The client’s home should be assessed to determine if the client needs assistance in the home.
Which would be an abnormal finding when doing a well-child checkup on a 1-week-old infant?
Show answer and rationale
Correct answer: D. An audible "clunk" during the Ortolani test.
an audible, low-pitched, "clunk" during the Ortolani test is caused by the sound of the femur head exiting or entering the acetabulum, indicating hip dislocation.
Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air?
Show answer and rationale
Correct answer: C. Allow the child to sit in a position of comfort.
the child with acute epiglottitis is likely to be restless and agitated due to the progressive airway obstruction. The child should be allowed to maintain a position of comfort (e.g., sitting upright) to avoid further agitation and impaired oxygenation.
A child recovering from abdominal surgery removes the nasogastric tube accidentally. A nurse replaces the nasogastric tube and places it to low wall suction. Two hours later, the nurse discovers that there is no drainage from the tube. What should be the nurse’s first action?
Show answer and rationale
Correct answer: B. Check the suction mechanism and settings.
the most likely cause of poor drainage is ineffective suction. The suction tubing may have become dislodged or the settings may have been altered. A nurse should inspect this first, then continue to problem-solve if needed.
A charge nurse is seated in front of a bank of cardiac monitors on a pediatric unit. There are four children receiving cardiac monitoring. Which finding should the charge nurse communicate at once to the child’s nurse?
Show answer and rationale
Correct answer: D. A heart rate of 160 in a 2-year-old child who is walking in the hallway.
the normal heart rate in a 2-year-old child is from 80 to 120 beats per minute. Even though the child is active, this heart rate is quite high and should be investigated further.
A school-age child visits a school nurse and states that a family member has been behaving inappropriately by touching the child near the groin area. What should be the school nurse’s priority action?
Show answer and rationale
Correct answer: B. Make a report to the proper child protective authorities as mandated by law.
the nurse’s priority is to fulfill the legal duties of a mandated reporter by contacting the agency responsible for taking reports of suspected child abuse.
Which child would be the best roommate for a 9-yearold child with myelodysplasia who is hospitalized for a foot infection?
Show answer and rationale
Correct answer: B. A 10-year-old with a fractured femur.
this child is close in age and development and is likely to be immobilized in the injured leg due to a cast and/or traction. Since the child with myelodysplasia is likely to have impaired mobility in the infected foot or even complete paralysis of both lower extremities, these children share similar limitations and the nursing staff can encourage them to play video games or participate in suitable activities.
A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply.
Show answer and rationale
Correct answer: A. Advancing diet as tolerated.
following tonsillectomy, the child may begin oral intake after surgery, beginning with ice chips and progressing as tolerated to avoid vomiting, which could injure the surgical site.
A nurse is caring for a child newly diagnosed with congenital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is:
Show answer and rationale
Correct answer: A. Increased heart rate.
the body tries to compensate for a failing heart by first increasing the heart rate as a way to increase circulating blood volume.
When teaching a class on home safety to new parents, on which type of exposure should a nurse focus as the primary cause of lead poisoning in children?
Show answer and rationale
Correct answer: B. Ingesting paint dust or chips from an old home.
the primary means of lead exposure in children results from ingestion. The presence of lead-based paint should be suspected in homes built prior to the late 1970s when these paints were discontinued. Children can ingest paint chips or dust by chewing on contaminated surfaces such as windowsills, and they can become exposed by playing in contaminated soil.
A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation?
Show answer and rationale
Correct answer: B. Refraining from sharing food and drinks is a good way to prevent meningitis infection.
meningitis is primarily spread through contact with droplets that arise from the nasopharynx of a person who is infected. Teenagers should be taught to not share food, drinks, or any other item that touches the nose or mouth of another person.
When providing anticipatory guidance to the parents of a child with hemophilia, a nurse should stress that:
Show answer and rationale
Correct answer: A. A soft toothbrush should be used to promote oral health.
a soft toothbrush will prevent trauma to the child’s gums (i.e., bleeding) while keeping the teeth clean.
When providing client teaching to the caregivers of a young child with sickle cell disease, a nurse should stress that:
Show answer and rationale
Correct answer: B. The child’s diet should include whole grains and leafy green vegetables.
these foods are high in fiber and folic acid. Fiber prevents constipation, a potential side effect of pain medication, and folic acid is needed for healthy red blood cell production.
A school nurse advises the dietary staff that a special lunch tray must be created for a student who has celiac disease. What recommendation should the nurse provide to the dietary staff?
Show answer and rationale
Correct answer: B. Beans and rice are suitable side dishes for this student.
beans and rice are acceptable foods for a child with celiac disease, who requires a gluten-free diet.
An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant’s dehydration is severe?
Show answer and rationale
Correct answer: C. The infant has weak pulses, poor skin turgor, and cool, mottled skin.
these symptoms describe a child with significantly diminished circulation as a result of dehydration. An infant with severe dehydration has weak to absent pulses, poor skin turgor, and cool, discolored skin.
When visiting the home of a school-age child who is dying, what would be the best action by a hospice nurse?
Show answer and rationale
Correct answer: D. Avoid correcting the child who is in denial about dying.
many children use denial as a defense mechanism in the face of their own death. A nurse should not take away the child’s defenses; rather, the nurse should be honest when answering the child’s questions while allowing the child to accept death when ready.
A nurse is preparing to administer an unpleasant-tasting liquid medication to a toddler. What is the best method for administering this medication?
Show answer and rationale
Correct answer: B. Ask the child to choose between two types of fluids as a chaser.
the child should be given a choice of fluid chaser to wash the unpleasant taste out of the mouth following ingestion of the medication. The child is not given a choice of whether or not to take the medication.
A nursing student prepares to administer eyedrops to a young child. What action by the nursing student should cause a registered nurse to intervene?
Show answer and rationale
Correct answer: A. The student schedules medication administration to occur just before lunchtime.
eye drops should be administered when they are least likely to interfere with an activity that requires effective vision. A nurse should intervene and advise the student that the child should eat lunch first.
A school nurse is creating an informational brochure for parents regarding the treatment of head lice. What form of treatment should the nurse caution against?
Show answer and rationale
Correct answer: B. Applying repeated doses of permethrin for as long as it takes until the infestation clears.
although permethrin is an over-the-counter medication for the treatment of pediculosis (head lice), repeated doses may become toxic over time; parents should be cautioned against such treatments. A nurse should stress that nonpharmacologic treatments such as nit removal may be more effective and pose less risk to the child.
The parents of a newborn infant ask a nurse how to prevent future ear infections. What is the best advice the nurse should provide these parents?
Show answer and rationale
Correct answer: C. Continue breastfeeding as close to the baby’s first birthday as possible.
infants who are exclusively breastfed have a decreased incidence of otitis media (ear infections) compared to those who are formula-fed.
A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions? Select all that apply.
Show answer and rationale
Correct answer: D. Complete a neurological assessment.
the nurse should assess the child thoroughly to determine whether the child’s neurological status has changed since the last assessment.
A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming nurses calls to say, "Sorry, I’ll be a few minutes late since I have a child home ill with the chickenpox." What type of assignment would be most acceptable for the nurse who will be late?
Show answer and rationale
Correct answer: A. The nurse should not be given an assignment and should be called off.
the nurse has been exposed to someone with varicella (chickenpox). The charge nurse must first determine the nurse’s varicella immune status before permitting the nurse to provide care.
A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse?
Show answer and rationale
Correct answer: D. Expiratory grunt.
grunting respirations indicate that the infant is attempting to increase positive airway pressure to prevent airway collapse.
While suctioning a child with a tracheostomy tube in place, a nurse discovers that the suction catheter will not advance inside the tracheostomy tube and the child is becoming pale and anxious, with noticeable suprasternal retractions. What should be the nurse’s priority action?
Show answer and rationale
Correct answer: D. Change the tracheostomy tube at once.
child is displaying symptoms of respiratory distress due to tracheostomy occlusion since the nurse is unable to pass the catheter through the tracheostomy tube. This is an emergency requiring the nurse to promptly change the tracheostomy tube.
While preparing for an admission, a nurse hears the alarm sound on the cardiac monitor of a child in the next bed. The nurse views the screen and sees what appears to be ventricular fibrillation. What is the best initial action by the nurse?
Show answer and rationale
Correct answer: D. Assess the child.
the nurse should first assess the child’s physical condition before assuming that the monitor is accurate. The monitor could be displaying an artifact as a result of the child’s activity.
Which response to hospitalization is a nurse most likely to observe in a 4-year-old child?
Show answer and rationale
Correct answer: C. Urinary frequency and fear of mutilation.
since preschoolers have great concerns over body mutilation and may demonstrate somatic symptoms as a response to the stress of hospitalization.
A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child’s care? Select all that apply.
Show answer and rationale
Correct answer: C. Risk for infection.
children with beta-thalassemia are at increased risk for infection due to the impaired oxygen-carrying capacity of their blood.
A 3-year-old child is hospitalized with multiple fractures as a result of a car accident. What is the best way for a nurse to assess this child’s pain level?
Show answer and rationale
Correct answer: D. Employ the FACES pain scale with every nursing assessment.
the FACES pain rating scale can be used with children as young as 3 years of age, and pain should be investigated with every nursing assessment.
What is the priority nursing diagnosis for an infant receiving treatment for hyperbilirubinemia?
Show answer and rationale
Correct answer: C. Deficient fluid volume.
an infant with hyperbilirubinemia will have increased fluid needs due to increased insensible fluid losses from phototherapy treatment and increased fluid losses resulting from loose stools as the bilirubin is eliminated through the bowels. Failure to monitor and treat potential fluid volume imbalances can quickly put the infant at risk for dehydration.
Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply.
Show answer and rationale
Correct answer: D. History of recent blood transfusion.
antibodies present in the transfused blood can inhibit the immune response to the immunization.
A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is prepared to care for the child when the student states:
Show answer and rationale
Correct answer: B. "I will look for any changes in the child’s respirations, pulse, or blood pressure."
this statement is evidence that the student understands that alterations in any of these vital signs could be an indication of worsening condition and should be promptly noted.
A child diagnosed with hypopituitarism is to begin receiving daily injections. At what time should a nurse instruct the child’s parents to administer the injection each day?
Show answer and rationale
Correct answer: D. At bedtime.
the child will be receiving growth hormone injections and these should be timed to simulate the body’s normal growth hormone peak that occurs within the first 2 hours of sleep.
An infant is hospitalized for congenital adrenal hyperplasia (CAH). Which medication should a nurse anticipate to be part of the child’s treatment plan?
Show answer and rationale
Correct answer: B. Cortisone.
since the child with congenital adrenal hyperplasia (CAH) is given cortisone to stop the increased production of adrenocorticotropic hormone (ACTH), thereby inhibiting adrenocorticoid secretion and virilization of girls/early genital development in boys.
A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child’s ear level. What should be the nurse’s priority action?
Show answer and rationale
Correct answer: B. Clamp the drain and complete a neurological assessment.
the external ventricular drain (EVD) should be at the level of the ventricles, or at the child’s ear level. When the EVD is too low, CSF can drain quickly and lead to neurologic complications. A nurse should prevent the CSF from draining any further and assess the child.
A nurse is planning to teach a group of 10-year-old children about drug and alcohol prevention. Which characteristics of this age group are important for the nurse to consider when developing the teaching plan? Select all that apply.
Show answer and rationale
Correct answer: D. These children are achievement-oriented.
this is a developmental characteristic of the school-age child. The teaching plan should include activities that allow the children to succeed, such as games with a drug-free focus.
A nurse visits the home of a young child to administer the Denver II developmental assessment. The child is unable to perform several required items, and the parent expresses concern regarding the child’s performance. What is the best way for the nurse to respond to the parent’s concerns?
Show answer and rationale
Correct answer: A. Offer the parent some skill-building activities and explain that the child will be reassessed in 2 weeks.
a "suspect" Denver II should be repeated in 1 to 2 weeks to rule out factors such as fatigue or illness that may influence the child’s performance. The parent is also provided some skill-building activities to enjoy with the child to encourage development.
A nurse is caring for a child with tetralogy of Fallot. Which assessment findings should the nurse expect? Select all that apply.
Show answer and rationale
Correct answer: A. Overriding aorta.
an overriding aorta is one of the components of tetralogy of Fallot. Answer 4 is correct because pulmonic stenosis is one of the components of tetralogy of Fallot. Answer 5 is correct because right ventricular hypertrophy is one of the components of tetralogy of Fallot.
The parents of a child recently discharged with acute spasmodic laryngitis contact a nurse to report that the child continues to have croupy coughing spells at nighttime but is otherwise fine. What should the nurse recommend?
Show answer and rationale
Correct answer: D. Treat the spasms by sitting in the bathroom while a hot shower runs.
the humidity of the shower will create an environment that is soothing to the child’s airway. Cool-mist humidifiers are also recommended for the child’s room to relieve the symptoms of spasmodic croup. Any of the croup syndromes may be treated with humidified air. In the case of acute spasmodic laryngitis, both warm mist and cool mist are acceptable interventions since the problem is airway spasm rather than severe inflammation.
A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the arms and legs. What should a nurse caution the child’s parents against?
Show answer and rationale
Correct answer: D. Immunization during eczema exacerbations.
the child should not receive immunizations during an acute exacerbation of eczema (atopic dermatitis), as this may lead to complications such as allergic reaction. The child with atopic dermatitis is experiencing an inflammatory response. Care should be directed at relieving inflammation and avoiding exposure to substances thought to trigger an immune response.
A nurse is working with a nursing student in caring for an infant who has just returned from the surgical recovery area following a cleft lip repair. Which action by the nursing student should cause the nurse to intervene?
Show answer and rationale
Correct answer: D. Offering the parents a regular bottle with which to feed the infant.
the infant should not be fed using a regular bottle. Postoperative feedings for the child with a cleft lip should be administered through special feeders to minimize trauma to the suture line. Since a cleft lip repair involves only the child’s upper lip, the nurse should perform interventions that reduce the risk of damage or infection at the operative location.
A school-age child visits a school nurse with complaints of dizziness and shaking. The nurse confirms that the child has a history of type 1 diabetes mellitus when the child becomes diaphoretic and begins to faint. What should be the nurse’s first action?
Show answer and rationale
Correct answer: C. Administer an injection of glucagon.
the child is demonstrating symptoms of severe hypoglycemia and the nurse must administer an emergency dose of glucagon to prevent the child from going into shock.
A nurse should suspect Hirschsprung’s disease in a child who has which type of stooling pattern?
Show answer and rationale
Correct answer: B. Thin, ribbon-like stools.
the child with Hirschsprung’s disease will have infrequent stools that appear thin and ribbon-like.
A nurse attempts to give a newborn infant the first bottle feeding. While sucking, the infant becomes cyanotic and coughs, and formula is seen coming out of the infant’s nose. What should be the nurse’s first action?
Show answer and rationale
Correct answer: B. Suction the child’s airway.
the nurse’s first action should be to clear the child’s airway of formula. Since this is the infant’s first feeding, the nurse should suspect a tracheoesophageal fistula (TEF) and should not attempt to feed the child again.
A nurse is caring for a newborn infant diagnosed with hypospadias. The parents ask when the surgical repair will be complete. The nurse knows that the most likely time for completion of the surgical repair will be:
Show answer and rationale
Correct answer: D. Nearer the child’s first birthday.
the surgical repair of hypospadias generally begins within the first few months of life and continues in stages, finishing between 6 and 18 months of age, before the child begins toilet training.
A clinic nurse has a follow-up appointment with an adolescent with juvenile idiopathic arthritis (JIA). What topic should be the nurse’s top priority?
Show answer and rationale
Correct answer: C. Avoidance of alcohol use.
adolescents with JIA are frequently prescribed medications that are taxing to the liver, including NSAIDs, such as naproxen sodium, and SAARDs (sloweracting antirheumatic drugs), such as methotrexate. Alcohol abuse could cause serious complications when taking these medications. A nurse’s top priority takes into consideration that the adolescent is facing increasing peer pressure to drink alcohol, which could lead to hepatotoxicity.
An RN and LVN/LPN are working as a team on a pediatric unit. Which task should the RN perform rather than delegating to the LVN/LPN?
Show answer and rationale
Correct answer: A. Change the dressing and examine the decubitus ulcer of a preschooler.
the RN should change the wound dressing and assess the condition of the decubitus.
A child is admitted with acute exacerbation of asthma. A physician orders 100% oxygen via mask. Which physician order should be a nurse’s next priority?
Show answer and rationale
Correct answer: A. Continuous inhaled albuterol.
the nurse’s priority is to alleviate airway inflammation, and administration of a beta agonist such as albuterol is recommended.
Which action by the nurse is correct for droplet precautions?
Show answer and rationale
Correct answer: B. Wears a surgical mask when within 3 feet of client.
a medical-surgical mask is indicated if the nurse will be within 3 feet of the client.
What health teaching should be included for a client being discharged home from an emergency department with an infection?
Show answer and rationale
Correct answer: A. If chills occur after 24 hours, check temperature and call provider if over 38.5�C.
chilling is an indication that the hypothalamus "thermostat" has been reset at a higher level, and the body feels cold until metabolism increases the temperature to the new "fever" level. Twenty-four hours after antibiotics have been started, the client should be feeling better. Chilling and fever may indicate that the antibiotic is not effective against the organism.
Following a head injury, a client has no cough or gag reflex. The correct nursing action for feeding this client is to:
Show answer and rationale
Correct answer: A. Use a feeding tube.
this client is at great risk for aspiration. The feeding tube bypasses the junction of the esophagus and trachea, where the aspiration could most likely occur.
Which technique is correct for reducing swelling after a traumatic injury to the ankle?
Show answer and rationale
Correct answer: B. Apply intermittent ice during the first 24 hours.
intermittent ice causes vasoconstriction and reduces swelling.
A nurse tells a client that the most effective treatment for a rash from lupus erythematosus is:
Show answer and rationale
Correct answer: C. Taking an antimalarial drug.
antimalarial drugs are one of the first lines of treatment for lupus. Topical steroids are also often used for skin rashes.
Following an auto accident, a client’s vital signs and hematocrit will be monitored for 24 hours for signs of internal bleeding. During this time, the client should receive:
Show answer and rationale
Correct answer: A. Nothing by mouth.
if internal bleeding is present, the client will need to go to surgery. Keep the client NPO to avoid surgical delays, aspiration risk, or leakage of ingested substances out of damaged viscera.
Postoperatively, a client’s fingers are cold and pale. Which action should a nurse take?
Show answer and rationale
Correct answer: B. Apply warm blankets.
decreased blood flow can cause fingers to be pale and cool, such as one might see with Raynaud’s phenomenon. Symptoms lessen when covered.
A client with cancer has anorexia and loss of weight. Which intervention should a nurse perform first?
Show answer and rationale
Correct answer: D. Giving megestrol and a diet of choice with nutritional supplements.
malnutrition in cancer clients is complicated and often difficult to manage. While megestrol stimulates appetite, nutritional supplements provide nutrients.
A client, who is nondiabetic and receiving 5% dextrose in one-half normal saline (D5 1 /2 NS) running at 125 mL/hr, has a blood sugar of 130 mg/dL on the morning chemistry panel. The client is concerned. It is most important for the nurse to:
Show answer and rationale
Correct answer: C. Explain the consequences of stress and IV fluids on blood sugar level.
this slight elevation in blood sugar may reflect a neuroendocrine response to stress or may be a result of the intravenous sugar. Additional testing would be required to determine if the client is prediabetic.
A nurse is planning care for a client admitted with chest pain after myocardial ischemia. Which outcome should the nurse document for this problem?
Show answer and rationale
Correct answer: B. Client rates pain 0 on scale of 1 (least) to 10 (worst).
continuing chest pain indicates continued ischemia. Treatment should be given until the pain is gone.
A woman who has received radiation therapy says that she feels like she is voiding through her vagina. This client may be experiencing:
Show answer and rationale
Correct answer: A. The development of a vesicovaginal fistula.
radiation damages tissue, and the healing process may not effectively keep the vagina and bladder separate. Bladder contraction could send urine through a fistula, to come out the vagina.
The correct nursing action for a client who has a nephrostomy tube would include:
Show answer and rationale
Correct answer: D. Irrigating, if ordered, with no more than 10 mL sterile NS.
a nephrostomy tube is inserted into the ureter, directly draining the kidney. The pelvis of the kidney cannot accommodate volumes greater than 10 mL. The procedure must be sterile.
Following perineal surgery, a client is at risk for a wound infection related to incontinence. The correct management of this problem is to:
Show answer and rationale
Correct answer: B. Insert a continuous indwelling catheter per order.
an indwelling catheter diverts urine away from the operative site, reducing risk of wound infection.
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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