NCLEX Pediatric Review with Explanations REAL
EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) | PROFESSOR VERIFIED
A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications
that the child may be experiencing airway obstruction include which of the following?
1. Nasal flaring and bradycardia
2. The child thrusts the chin forward and opens the mouth
3. A low-grade fever and complaints of a sore throat
4. The child leans backward, supporting himself or herself with the hands and arms
Correct Answer✔✔: 2
Explanations: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward
supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, TACHYCARDIA, a high fever, and
a sore throat.
.
A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health
care provider's prescription should the nurse question?
1. Obtain a throat culture.
2. Obtain axillary temperatures.
3. Administer humidified oxygen.
4.Administer antipyretics for fever.
Correct Answer✔✔: 1
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.
,A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is
worsening?
1. Warm, dry skin
2. Increased wheezing
3. Decreased wheezing
4. A pulse rate of 90 beats per minute
Correct Answer✔✔: 3
Explanations: Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign,
when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With
treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an
improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-
year-old is 70 to 110 beats per minute.
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that
the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural
drainage?
Correct Answer✔✔: 10:00 am, 2:00 pm, 8:00 pm
Explanations: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent
vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is
also important to perform these treatments before bedtime to clear airways and facilitate rest.
.
The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of
consciousness diminishes, which is a priority intervention?
1. Taking the apical pulse
, 2. Taking the blood pressure
3.Testing the urine for protein
4.Palpating the anterior fontanel
Correct Answer✔✔: 4
A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse
and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue
in an infant.
The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. Which time of the month should
the nurse tell the client to perform breast self-examination?
1. At ovulation time
2. 7 to 10 days after menses
3. Just before the menses begins
4. On a specific day of the month and on that same day every month thereafter
Correct Answer✔✔: 4
Explanations: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day
every month. Options 2 and 3 are inappropriate because the client who had a hysterectomy would not be menstruating. It is
best not to perform the BSE at ovulation time because of the hormonal changes that occur.
A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to a pain crisis.
Which of the following, if identified by the mother as the precipitating factor, indicates the need for further instructions?
1. infection
2. trauma
3. fluid overload
4. stress
Correct Answer✔✔: 3) Fluid Overload
Explanations: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The
mother of a child with sickle cell disease should encourage fluid intake of 1.5-2 times the daily requirement to prevent
dehydration.
EXAM QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) | PROFESSOR VERIFIED
A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications
that the child may be experiencing airway obstruction include which of the following?
1. Nasal flaring and bradycardia
2. The child thrusts the chin forward and opens the mouth
3. A low-grade fever and complaints of a sore throat
4. The child leans backward, supporting himself or herself with the hands and arms
Correct Answer✔✔: 2
Explanations: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward
supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, TACHYCARDIA, a high fever, and
a sore throat.
.
A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health
care provider's prescription should the nurse question?
1. Obtain a throat culture.
2. Obtain axillary temperatures.
3. Administer humidified oxygen.
4.Administer antipyretics for fever.
Correct Answer✔✔: 1
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.
,A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is
worsening?
1. Warm, dry skin
2. Increased wheezing
3. Decreased wheezing
4. A pulse rate of 90 beats per minute
Correct Answer✔✔: 3
Explanations: Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign,
when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With
treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an
improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-
year-old is 70 to 110 beats per minute.
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that
the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural
drainage?
Correct Answer✔✔: 10:00 am, 2:00 pm, 8:00 pm
Explanations: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent
vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is
also important to perform these treatments before bedtime to clear airways and facilitate rest.
.
The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of
consciousness diminishes, which is a priority intervention?
1. Taking the apical pulse
, 2. Taking the blood pressure
3.Testing the urine for protein
4.Palpating the anterior fontanel
Correct Answer✔✔: 4
A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse
and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue
in an infant.
The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. Which time of the month should
the nurse tell the client to perform breast self-examination?
1. At ovulation time
2. 7 to 10 days after menses
3. Just before the menses begins
4. On a specific day of the month and on that same day every month thereafter
Correct Answer✔✔: 4
Explanations: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day
every month. Options 2 and 3 are inappropriate because the client who had a hysterectomy would not be menstruating. It is
best not to perform the BSE at ovulation time because of the hormonal changes that occur.
A clinic nurse instructs the mother of a child with sickle cell disease about the precipitating factors related to a pain crisis.
Which of the following, if identified by the mother as the precipitating factor, indicates the need for further instructions?
1. infection
2. trauma
3. fluid overload
4. stress
Correct Answer✔✔: 3) Fluid Overload
Explanations: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The
mother of a child with sickle cell disease should encourage fluid intake of 1.5-2 times the daily requirement to prevent
dehydration.
