NUR 114
EXAM 4
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child with burns during treatment. Which assessment
provides the most accurate guide to determine the adequacy of fluid
resuscitation?
1. Skin turgor
2. Level of edema at burn site
3. Adequacy of capillary filling
4. Amount of fluid tolerated in 24 hours
Answer: 3
Rationale: Parameters such as vital signs (especially heart rate), urinary output
volume, adequacy of capillary filling, and state of sensorium determine adequacy
of fluid resuscitation. Although options 1, 2, and 4 may provide some information
related to fluid volume, in a burn injury, and from the options provided, adequacy
of capillary filling is most accurate.
Test-Taking Strategy: Note the strategic word, most. Use the ABCs—airway,
breathing, and circulation—to assist in directing you to the correct option.
The nurse caring for a child who sustained a burn injury plans care based on
which pediatric considerations associated with this injury? Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of infection for
infants and young children.
4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of
the total body surface area.
5. The lower proportion of body fluid to body mass in a child increases the risk
of cardiovascular problems.
6. Infants and young children are at increased risk for protein and calorie
deficiency, because they have smaller muscle mass and less body fat than
adults.
Answer: 2, 3, 6
,Rationale: Pediatric considerations in the care of a burn victim include the
following: Scarring is more severe in a child than in an adult. A delay in growth
may occur after a burn injury. An immature immune system presents an increased
risk of infection for infants and young children. The higher proportion of body fluid
to body mass in a child increases the risk of cardiovascular problems. Burns
involving more than 10% of total body surface area require some form of fluid
resuscitation. Infants and young children are at increased risk for protein and
calorie deficiencies because they have smaller muscle mass and less body fat than
adults.
Test-Taking Strategy: Focus on the subject, pediatric considerations in the care of a
child who has sustained a burn injury. To answer correctly, read each option
carefully and think about the physiology of a child related to body size.
The nurse provides home care instructions to the parents of a child with heart
failure regarding the procedure for administration of digoxin. Which statement
made by the parent indicates the need for further instruction?
1. "I will not mix the medication with food."
2. "If more than one dose is missed, I will call the pediatrician."
3. "I will take my child's pulse before administering the medication."
4. "If my child vomits after medication administration, I will repeat the dose."
Answer: 4
Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if
the child vomits after digoxin is administered, they are not to repeat the dose.
Options 1, 2, and 3 are accurate instructions regarding the administration of this
medication. In addition, the parents need to be instructed that if a dose is missed
and the missed dose is not identified until 4 hours later, the dose would not be
administered.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is an
incorrect statement. General knowledge regarding digoxin administration will
assist in eliminating option 2. Principles related to administering medications to
, children will assist in eliminating option 1. From the remaining options, select the
correct option because if the child vomits, it would be difficult to determine
whether the medication also was vomited or was absorbed by the body.
The nurse is closely monitoring the intake and output of an infant with heart
failure who is receiving diuretic therapy. The nurse would use which most
appropriate method to assess the urine output?
1. Weighing the diapers
2. Inserting a urinary catheter
3. Comparing intake with output
4. Measuring the amount of water added to formula
Answer: 1
Rationale: Heart failure is the inability of the heart to pump a sufficient amount of
blood to meet the oxygen and metabolic needs of the body. The most appropriate
method for assessing urine output in an infant receiving diuretic therapy is to
weigh the diapers. Comparing intake with output would not provide an accurate
measure of urine output. Measuring the amount of water added to formula is
unrelated to the amount of output. Although urinary catheter drainage is most
accurate in determining output, it is not the most appropriate method in an infant
and places the infant at risk for infection.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate
options 3 and 4 first because they are comparable or alike and will not provide an
indication of urine output. Noting the strategic words will direct you to the correct
option from the remaining options.
The clinic nurse reviews the record of a child just seen by the pediatrician and
diagnosed with suspected aortic stenosis. The nurse expects to note
documentation of which clinical manifestation specifically found in this
disorder?
1. Pallor
2. Hyperactivity
EXAM 4
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child with burns during treatment. Which assessment
provides the most accurate guide to determine the adequacy of fluid
resuscitation?
1. Skin turgor
2. Level of edema at burn site
3. Adequacy of capillary filling
4. Amount of fluid tolerated in 24 hours
Answer: 3
Rationale: Parameters such as vital signs (especially heart rate), urinary output
volume, adequacy of capillary filling, and state of sensorium determine adequacy
of fluid resuscitation. Although options 1, 2, and 4 may provide some information
related to fluid volume, in a burn injury, and from the options provided, adequacy
of capillary filling is most accurate.
Test-Taking Strategy: Note the strategic word, most. Use the ABCs—airway,
breathing, and circulation—to assist in directing you to the correct option.
The nurse caring for a child who sustained a burn injury plans care based on
which pediatric considerations associated with this injury? Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of infection for
infants and young children.
4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of
the total body surface area.
5. The lower proportion of body fluid to body mass in a child increases the risk
of cardiovascular problems.
6. Infants and young children are at increased risk for protein and calorie
deficiency, because they have smaller muscle mass and less body fat than
adults.
Answer: 2, 3, 6
,Rationale: Pediatric considerations in the care of a burn victim include the
following: Scarring is more severe in a child than in an adult. A delay in growth
may occur after a burn injury. An immature immune system presents an increased
risk of infection for infants and young children. The higher proportion of body fluid
to body mass in a child increases the risk of cardiovascular problems. Burns
involving more than 10% of total body surface area require some form of fluid
resuscitation. Infants and young children are at increased risk for protein and
calorie deficiencies because they have smaller muscle mass and less body fat than
adults.
Test-Taking Strategy: Focus on the subject, pediatric considerations in the care of a
child who has sustained a burn injury. To answer correctly, read each option
carefully and think about the physiology of a child related to body size.
The nurse provides home care instructions to the parents of a child with heart
failure regarding the procedure for administration of digoxin. Which statement
made by the parent indicates the need for further instruction?
1. "I will not mix the medication with food."
2. "If more than one dose is missed, I will call the pediatrician."
3. "I will take my child's pulse before administering the medication."
4. "If my child vomits after medication administration, I will repeat the dose."
Answer: 4
Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if
the child vomits after digoxin is administered, they are not to repeat the dose.
Options 1, 2, and 3 are accurate instructions regarding the administration of this
medication. In addition, the parents need to be instructed that if a dose is missed
and the missed dose is not identified until 4 hours later, the dose would not be
administered.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is an
incorrect statement. General knowledge regarding digoxin administration will
assist in eliminating option 2. Principles related to administering medications to
, children will assist in eliminating option 1. From the remaining options, select the
correct option because if the child vomits, it would be difficult to determine
whether the medication also was vomited or was absorbed by the body.
The nurse is closely monitoring the intake and output of an infant with heart
failure who is receiving diuretic therapy. The nurse would use which most
appropriate method to assess the urine output?
1. Weighing the diapers
2. Inserting a urinary catheter
3. Comparing intake with output
4. Measuring the amount of water added to formula
Answer: 1
Rationale: Heart failure is the inability of the heart to pump a sufficient amount of
blood to meet the oxygen and metabolic needs of the body. The most appropriate
method for assessing urine output in an infant receiving diuretic therapy is to
weigh the diapers. Comparing intake with output would not provide an accurate
measure of urine output. Measuring the amount of water added to formula is
unrelated to the amount of output. Although urinary catheter drainage is most
accurate in determining output, it is not the most appropriate method in an infant
and places the infant at risk for infection.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate
options 3 and 4 first because they are comparable or alike and will not provide an
indication of urine output. Noting the strategic words will direct you to the correct
option from the remaining options.
The clinic nurse reviews the record of a child just seen by the pediatrician and
diagnosed with suspected aortic stenosis. The nurse expects to note
documentation of which clinical manifestation specifically found in this
disorder?
1. Pallor
2. Hyperactivity
