NCLEX Sample Questions Pediatric Nursing Part 2 Answers and Rationale

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  1. Answer C. In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a friend.
  2. Answer C. The nurse always should reinforce safety guidelines when teaching parents how to care for their child. By giving anticipatory guidance the nurse can help prevent many accidental injuries. For parents of a 9-month-old infant, it is too early to discuss nursery schools or toilet training. Because surgery is not used gastroenteritis, this topic is inappropriate.
  3. Answer C. The nurse should start screening a child for lead poisoning at age 18 months and perform repeat screening at age 24, 30, and 36 months. High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months. Regular dental visits should begin at age 24 months.
  4. Answer D. The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations, altered white blood cell or platelet counts are not specific signs of metabolic imbalance.
  5. Answer C. A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. The other options are incorrect because signs and symptoms will reappear if the patient eats prohibited foods.
  6. Answer C. By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
  7. Answer A. Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.
  8. Answer D. The nurse caring for an infant with nonorganic failure to thrive should maintain a consistent, structured environment that provides interaction with the infant to promote growth and development. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
  9. Answer B. Children with spina bifida often develop an allergy to latex and shouldn’t be exposed to it. If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex. Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy.
  10. Answer A. The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.
  11. Answer B. The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement, although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access.
  12. Answer D. One of the most valuable clues to pain is a behavior change: A child who’s pain-free likes to play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased urine output may signify dehydration.
  13. Answer C. Nursing care plan should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.
  14. Answer A. Accidents are the major cause of death and disability during the school-age years. Therefore, accident prevention should take priority when teaching parents of school-age children. Preschool (not school-age) children are afraid of the dark, have fears concerning body integrity, and should be encouraged to dress without help (with the exception of tying shoes).
  15. Answer C. Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. The other three options would be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take priority over documentation.
  16. Answer D. The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child, two-person rescue may be inappropriate. For a child, the nurse should deliver 20 breaths/minute instead of 12.
  17. Answer A. Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.
  18. Answer A. If the child isn’t developmentally ready, child and parent will become frustrated. Consistency is important once toilet training has already started. The mother’s positive attitude is important when the child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.
  19. Answer A. When children are minors and aren’t emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.
  20. Answer A. The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.
  21. Answer D. The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.
  22. Answer C. Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible.
  23. Answer D. The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t recommend whole milk until age 12 months, and skim milk until after age 2 years.
  24. Answer C. Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. Baby wipes contain alcohol, which may worsen the condition. Extra fluids won’t make the rash better.
  25. Answer C. Before interviewing in any way, the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe.
  26. Answer A.Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Body image disturbance, impaired urinary elimination, and infection are all integral parts of burn management but aren’t the first priority.
  27. Answer A. Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit.
  28. Answer D. A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. An oxygen saturation of 95%, mild work of breathing, and absence of intercostals or substernal retractions are all normal findings.
  29. Answer A. Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumber puncture isn’t appropriate.
  30. Answer A. Itching underneath a cast can be relieved by directing blow-dyer, set, on the cool setting, toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch.


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