Pediatric NCLEX Questions

Pediatric NCLEX Questions Related

Review Pediatric NCLEX Questions related questions and content

The nurse is working on the pediatric floor, caring for an infant who is very fussy and has a diagnosis of DI. Which parameter should the nurse monitor while the infant is on fluid restrictions?

  • A. Oral intake.
  • B. Urine output.
  • C. Appearance of the mucous membranes.
  • D. Pulse and temperature. 116
Correct Answer: B

Rationale: In a patient with diabetes insipidus (DI) who is on fluid restrictions, monitoring urine output is crucial to assess the effectiveness of the treatment regimen. DI is a condition characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH). By monitoring urine output, the nurse can determine if the restrictions are achieving the goal of decreasing urine volume and preventing dehydration. Changes in urine output can also indicate the need for adjustments in the treatment plan. Monitoring oral intake, appearance of mucous membranes, and pulse and temperature are important aspects of pediatric care but are not as directly related to managing fluid restrictions in a patient with DI.

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Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

  • A. Face
  • B. Buttocks TestBankWorld.org
  • C. Oral mucosa
  • D. Palms and soles
Correct Answer: C

Rationale: Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding into the skin. In dark-skinned individuals, it can be challenging to visualize petechiae due to the pigmentation of the skin. However, one of the best places to observe for the presence of petechiae in dark-skinned individuals is the oral mucosa, specifically the inner lining of the mouth. The oral mucosa is usually lighter in color compared to the skin, making it easier to identify petechiae in this area. Palms and soles may also be a good place to observe for petechiae, but the oral mucosa is typically the preferred site for examination in dark-skinned individuals.

The child begins to understand right and left by age of

  • A. 3 yr
  • B. 4 yr
  • C. 5 yr
  • D. 6 yr
Correct Answer: C

Rationale: Understanding right and left typically develops around age 5.

An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a routine blood draw. Which interventions should the nurse implement? Place in order from the highest-priority intervention to the lowest-priority intervention. Provide the answer using lowercase letters separated by commas (e.g., a, b, c, d).

  • A. Administer 100% oxygen by blow-by.
  • B. Place the infant in knee-chest position.
  • C. Remain calm.
  • D. Give morphine subcutaneously or by an existing intravenous line.
Correct Answer: B

Rationale: Highest-priority intervention: Place the infant in the knee-chest position. This position can help increase systemic vascular resistance and reduce the shunting of blood from right to left in tetralogy of Fallot, temporarily improving oxygenation.

The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. What is the rationale for this position?

  • A. It prevents cremasteric reflex.
  • B. Undescended testes can be palpated.
  • C. This tests the child for an inguinal hernia.
  • D. The child does not yet have a need for privacy.
Correct Answer: A

Rationale: The "tailor" position, also known as the frog-leg position, is used during palpation for the testes in young boys because it helps prevent the cremasteric reflex. The cremasteric reflex is a normal reflex in which the testes are pulled upwards towards the inguinal canal when the inner thigh is stroked. By having the child sit in the tailor position, with the knees pulled up and legs rotated outwards, the reflex is less likely to be elicited, allowing for a more accurate examination of the testes.

The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

  • A. pupil size, response to pain, motor responses
  • B. Pupil size, verbal response, motor response
  • C. Eye opening, verbal response, motor response
  • D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C

Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.

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