NCLEX Practice Exam: Pediatric Nursing Answers and Rationale

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1. B. When administering chemotherapy, the nurse should observe for an anaphylactic reaction for 20 minutes and stop the medication if one is suspected. Chemotherapy is associated with both general and specific adverse effects, therefore close monitoring for them is important.

2. D. When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive. Starting at the head or abdomen is intrusive and should be avoided. Proceeding from distal to proximal is inappropriate at any age.

3. C. Rheumatic fever results as a delayed reaction to inadequately treated group A β-hemolytic streptococcal infection.

4. A. The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation

5. D. Mycostatin suspension is given as swab. Never mix medications with food and formula.

6. C. If the child is hungry he/she more likely would finish his meals. Therefore, the mother should be advised not to give snacks to the child. The child is a “busy toddler.” He/she will not able to keep still for a long time.

7. D. Normal heart rate of the newborn is 120 to 160 bpm. Choices A, B, and C are normal assessment findings (uneven head shape is molding).

8. A. Lead poisoning may be caused by inhalation of dusk and smoke from leaded gas. It may also be caused by lead-based paint, soil, water (especially from plumbings of old houses).

9. A. Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessive hereditary disease characterised by abnormally low levels of glucose-6-phosphate dehydrogenase (abbreviated G6PD or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.

10. C. For the child with iron deficiency anemia, the blood study results most likely would reveal decreased mean corpuscular volume (MCV) which demonstrates microcytic anemia, decreased hemoglobin, decreased hematocrit and elevated total iron binding capacity.

11. D. The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself.

12. A. During this period, which lasts up to the age of 18-21 years, the individual develops a sense of “self.” Peers have a major big influence over behavior, and the major decision is to determine a vocational goal.

13. C. Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say “mama” in the sense that it refers to their mother at this time.

14. A. By 12 months, 50 percent of children can walk well.

15. C. Lying flat keeps the patient from having a “spinal headache.” Increasing the fluid intake will assist in replenishing the lost fluid during this time.

16. C. The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.

17. A. Bronchodilators can produce the side effects listed in answer choice (A) for a short time after the patient begins using them.

18. D. Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.

19. C. The glycosolated hemoglobin test measures glucose levels for the previous 3 to 4 months.

20. D. Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important.