Example of NCLEX Exam Questions with Answer (Child Health) 24th Edition
Example of NCLEX Exam Questions with Answer (Child Health) 24th Edition
1. A child with croup is placed in a cool-mist tent. The mother asks if the child can have his or her security blanket inside the tent. The appropriate response is:
A. “Objects from home are not allowed to be brought to the hospital.”
B. “The child may have the security blanket inside the tent.”
C. “The blanket is not allowed because it will promote the growth of bacteria.”
D. “The blanket is not allowed but the child may have a toy from the hospital play room.”
Answer: B. “The child may have the security blanket inside the tent.”
Rationale: Familiar objects provide a sense of security for children in the strange hospital environment. The child is allowed to have a favorite toy or blanket while in the mist tent. Options 1, 3, and 4 are inappropriate statements.
Test-Taking Strategy: Use the process of elimination and note the key words cool-mist tent. Option 1 can be easily eliminated first. Next eliminate options 3 and 4 because they are similar. Also, remember that a warm environment (not cool) promotes the growth of bacteria. Review care to the child in a mist tent if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 188.
2. A mother arrives at the emergency room with her child, and a diagnosis of epiglottitis is documented for the child. Which of the following physician orders would be most important for the nurse to question?
A. Obtain a throat culture
B. Obtain axillary temperatures
C. Administer humidified oxygen
D. Administer antipyretics for fever
Answer: A. Obtain a throat culture
Rationale: The throat of a child with suspected epiglottitis should not be examined or cultured, because any stimulation with a tongue depressor or culture swab could cause laryngospasm and complete airway obstruction. Humidified oxygen and antipyretics are components of the treatment. Axillary rather than oral temperatures should be taken.
Test-Taking Strategy: Use the process of elimination. Recalling the high probability for complete airway obstruction in a child with epiglottitis will direct you to option A. Review care to the child with epiglottitis if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 191.
3. An emergency room nurse is gathering initial data on a child suspected of epiglottitis. The nurse’s priority would be to:
A. Prepare the child for an x-ray
B. Assist the physician with intubation
C. Prepare the child for tracheotomy
D. Assess for a patent airway
Answer: D. Assess for a patent airway
Rationale: When epiglottitis is suspected, the priorities are to maintain a patent airway and to obtain an x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate construction of a surgical airway. Although options 1, 2, and 3 may be components of care, they are not the priority.
Test-Taking Strategy: Note the key word priority in the question. Use the ABCs—airway, breathing, and circulation—to direct you to option D. Review care to the child with suspected epiglottitis if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 190.
4. A nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which of the following as the most reliable method of determining fluid loss?
A. Intake
B. Output
C. Skin turgor
D. Body weight
Answer: D. Body weight
Rationale: Body weight is the most reliable method of measurement of body fluid loss or gain. One kilogram of weight change represents 1 liter of fluid loss or gain. Although options 1, 2, and 3 may be used to determine fluid status, they are not the most reliable determinants.
Test-Taking Strategy: Use the process of elimination and note the key words most reliable. Options 1 and 2 can be eliminated first because they both relate to fluid status. Also, it would be very difficult to obtain an accurate output on an infant. From the remaining options, focusing on the key words will direct you to option D. Review care to the infant with dehydration if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 597, 672.
5. Ribavirin (Virazole) is prescribed for the hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which of the following routes?
A. Intravenously
B. Intramuscularly
C. Via facemask
D. Orally
Answer: C. Via facemask
Rationale: Ribavirin is an antiviral respiratory medication that is used mainly in hospitalized children with severe RSV and in high-risk children. Administration is via hood, facemask, or oxygen tent. The medication is most effective if administered within the first 3 days of the illness.
Test-Taking Strategy: Knowledge regarding the administration of this medication is required to answer this question. Remember, administration of this medication is via hood, facemask, or oxygen tent. Review this medication if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 598
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