Silvestri NCLEX Questions (EXAM 2)

The mother of a hospitalized 2-year old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make? a. The child may be allergic to antibiotics b. The child is too young to receive antibiotics c. Antibiotics are not indicated unless a bacterial infection is present d. The child still has the maternal antibiotics from birth and does not need antibiotic

c. Antibiotics are not indicated unless a bacterial infection is present

The nurse is monitoring a child with burns during treatment. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? a. Skin turgor b. Level of edema at burn site c. Adequacy of capillary refilling d. Amount of fluid tolerated in 24 hours

c. Adequacy of capillary refilling

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? a. Watery diarrhea b. Ribbon like stool c. Profuse projectile vomiting d. Bright red blood and mucus in stools

d. Bright red blood and mucus in stools

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? a. Ensure that all ropes are outside the pulleys b. Ensure that the weights are resting lightly on the floor c. Restrict diversional and play activities until the child is out of traction d. Check the primary health care provider's prescriptions for the amount of weight to be applied

d. Check the primary health care provider's prescriptions for the amount of weight to be applied

The nurse is preparing to care for a 5 year old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? a. A radio b. A sports video c. Large picture books d. Crayons and a coloring book

d. Crayons and a coloring book

The mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? a. Increase dose of ibuprofen b. Increase frequency of ibuprofen c. Encourage the child to lie on the left side d. Encourage the child to lie on the right side

d. Encourage the child to lie on the right side

The clinic nurse reviews the record of an infant and notes that the primary health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? a. Diarrhea b. Projectile vomiting c. Regurgitation of feedings d. Foul smelling ribbon like stools

d. Foul smelling ribbon like stools

Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? a. Did your child fall off a bike onto the handlebars b. Has the child had persistent nausea and vomiting c. Has the child been itching or had a rash anytime in the last week d. Has the child had a sore throat in the last few weeks

d. Has the child had a sore throat in the last few weeks

The nurse is caring for a child diagnosed with erythema infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child? a. An intense fiery red edematous rash on the cheeks b. Pinkish rose maculopapular rash on the face, neck, and scalp c. Reddish and pinpoint petechiae spots on the soft palate d. Small bluish white spots with red a base found on the buccal mucosa

a. An intense fiery red edematous rash on the cheeks

The mother of a 3 year old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? a. Fine grayish red lines b. Purple colored lesions c. Thick, honey-colored crusts d. Clustered of fluid filled vesicles

a. Fine grayish red lines

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? a. Frequent swallowing b. A decreased pulse rate c .Complaints of discomfort d .An elevation in blood pressure

a. Frequent swallowing

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply a. Pallor b. Edema c. Anorexia d. Proteinuria e .Weight loss f. Decreased serum lipids

a. Pallor b. Edema c. Anorexia d. Proteinuria

The nurse is preparing for the admission of an infant with a diagnosis of bronchitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. a. Place the infant in a private room b. Ensure that the infant's head is in a flexed position c .Wear a mask, gown and gloves when in contact with the infant d. Place the infant in a tent that delivers warm humidified air. e. Position the infant on the side, with the head lowers than the chest f .Ensure that the nurses caring for the infant with RSV do not care for other high risk children

a. Place the infant in a private room c .Wear a mask, gown and gloves when in contact with the infant f .Ensure that the nurses caring for the infant with RSV do not care for other high risk children

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. a. Provide a soft diet b. Position the child on the left side c .Administer an antihistamine twice daily d. Irrigate the right ear with normal saline every 8 hours e. Administer ibuprofen for fever every 4 hours as prescribed and as needed f. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy

a. Provide a soft diet e. Administer ibuprofen for fever every 4 hours as prescribed and as needed f. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? a. Turn the child to the side b. Administer the prescribed antiemetic c. Maintain NPO status d. Notify the primary health care provider

a. Turn the child to the side

A 2 year old is treated in the emergency department for a burn to chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? a. We will be sure not to leave hot liquids unattended b. I guess our children need to understand what the word hot means c. We will be sure that the children stay in their rooms when we work in the kitchen d. We will install a safety gate as soon as we get home so the children cannot get into kitchen

a. We will be sure not to leave hot liquids unattended

The nurse is caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. a. Scarring is less severe in a child than in an adult b. A delay in growth may occur after a burn injury c. An immature immune system presents an increase risk of infection for infants and young children d. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area e. The lower portion of body fluid to body mass in a child increases the risk of cardiovascular problems f. 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

b. A delay in growth may occur after a burn injury c. An immature immune system presents an increase risk of infection for infants and young children f. 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

the clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. a. Child has symptoms of a cold b. Child had a previous anaphylactic reaction to the vaccine c. The mother reports that the child is having intermittent episodes of diarrhea d. The mother reports that the child has not had an appetite and has been fussy e. The child has a disorder that causes a severely deficient immune system f, The mother reports that the child has been recently been exposed to an infectious disease

b. Child had a previous anaphylactic reaction to the vaccine e. The child has a disorder that causes a severely deficient immune system

A 10 year old with asthma is treated for acute exacerbation in the ER. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a. Warm, dry skin b. Decreased wheezing c. Pulse rate of 90 beats per minute d. respirations of 18 breaths per minute

b. Decreased wheezing

The nurse performing an admission assessment on a 2 year old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? a. Hypertension b. Generalized edema c. Increased urinary output d. Frank, bright red blood in urine

b. Generalized edema

A 4 year old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? a. The cast may feel warm as the cast dries b. I can use lotion or powder around the cast edges to relieve itching c. A small amount of white shoe polish can touch up a soiled white cast d. If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast

b. I can use lotion or powder around the cast edges to relieve itching

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis? a. His pediatrician said his kidneys are working well b. I noticed his urine was color of cola lately c. I'm so glad they didn't find any protein in his urine d. The nurse who admitted my child said his blood pressure was low

b. I noticed his urine was color of cola lately

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. a. Use the fingertips to lift the cast while it is drying b. Keep small toys and sharp objects away from the cast c. Use a padded ruler or another padded object to scratch the skin under the cast if it itches d. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold e. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling f. Contact the primary health care provider if the child complains of numbness or tingling in the extremity

b. Keep small toys and sharp objects away from the cast e. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling f. Contact the primary health care provider if the child complains of numbness or tingling in the extremity

The nurse is caring for an infant with bronchiolitis and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? a. Initiate strict enteric precautions b. Move the infant to a private room c. Leave the infant in the present room, because RSV is not contagious d. Inform the staff that using standard precautions is all that is necessary when caring for the child

b. Move the infant to a private room

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? a. Watery diarrhea b. Projectile vomiting c. Increased urine output d. Vomiting large amounts of bile

b. Projectile vomiting

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines which laboratory value is most significant to review? a. Creatinine level b. Prothrombin Time c. Sedimentation rate d. BUN level

b. Prothrombin Time

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? a. Supine b. Side lying c. High-fowler's d. Trendelenburg

b. Side lying

After a tonsillectomy, the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question? a. Monitor for bleeding b. Suction every 2 hours c. Give no milk or milk products d. Give clear, cool liquids when awake and alert

b. Suction every 2 hours

The emergency department nurse is caring for a child diagnosed with epiglottis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? a. The child exhibits nasal flaring and bradycardia b. The child is leaning forward with the chin thrust out c. The child has a low grade fever and complains of a sore throat d. The child is leaning backward, supporting herself or himself with hands and arm

b. The child is leaning forward with the chin thrust out

The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment? a. Has your child had difficulty urinating? b. Has your child been exposed to anyone with chickenpox? c. Has any family member had a sore throat within the past few weeks? d. Has any family member had a gastrointestinal disorder in past few weeks?

c. Has any family member had a sore throat within the past few weeks?

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parent indicates a need for further instruction? a. I will encourage my child to perform prescribed exercises b. I will have my child wear soft fabric clothing under the brace c. I should apply lotion under the brace to prevent skin breakdown d. I should avoid the use of powder because it will cake under the brace

c. I should apply lotion under the brace to prevent skin breakdown

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in the best position at this time? a. Prone position b .On the stomach c. Left lateral position d. Right lateral position

c. Left lateral position

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? a. It is extremely contagious b. It is most common in humid weather c. Lesions most often are located on the arms and chest d. It might show up in area of broken skin, such as an insect bite

c. Lesions most often are located on the arms and chest

An infant receives a diphtheria, tetanus, and acellular pertussis immunization at a well baby clinic. The parent returns home and calls the clinical to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? a. Monitor infant for fever b. Bring infant back to clinic c. Apply a hot pack to the injection site d. Apply a cold pack to the injection site

d. Apply a cold pack to the injection site

A new parent expresses concern to the nurse regarding sudden infant death syndrome. She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? a. Side or prone b .Back or prone c. Stomach with face turned d. Back rather than on the stomach

d. Back rather than on the stomach

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, constantly crying and trying to climb out of the tent. Which is the most appropriate nursing action? a. Tell the mother that the child must stay in the tent b. Place a toy in the tent to make the child feel more comfortable c. Call the pediatrician and obtain prescription for a mild sedative d. Let the mother hold the child and direct the cool mist over the child's face

d. Let the mother hold the child and direct the cool mist over the child's face

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? a. Administer an analgesic b. Release the skin traction c. Apply ice to the extremity d. Notify the primary health care provider

d. Notify the primary health care provider

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distension. On the basis of these findings, the nurse should take which action? a. Administer an antiemetic b. Increase the IV fluids c. Place the child in a Sims' position d. Notify the primary healthcare provider

d. Notify the primary healthcare provider

The nurse is caring for a child diagnosed with rubeola (measles) notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected? a. Pinpoint petechiae noted on both legs b. Whitish vesicles located across the chest c. Petechiae spots that reddish and pinpoint on the soft palate d. Small, blue-white spots with a red base found on the buccal mucosa

d. Small, blue-white spots with a red base found on the buccal mucosa

The nurse provides feedings instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a. Provide less frequent, larger feedings b. Burp the infant less frequently during feedings c. Thin the feedings by adding water to the formula d. Thicken the feedings by adding rice cereal to the formula

d. Thicken the feedings by adding rice cereal to the formula

The nurse provides home care instruction to the parents a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. What statement by a parent indicates a need for further instruction? a. We need to encourage our child to drink fluids b. Coughing spells may be triggered by dust or smoke c. Vomiting may occur when our child has coughing episodes d. We need to maintain droplet precautions and a quiet environment for at least 2 weeks

d. We need to maintain droplet precautions and a quiet environment for at least 2 weeks

The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a positive head check for lice? a. Maculopapular lesions behind the ears b. lesions in the scalp that extend to the hairline or neck c. White flaky particles throughout the entire scalp region d. White sacs attached to the hair shafts in the occipital area

d. White sacs attached to the hair shafts in the occipital area