NCLEX 1
A nurse is monitoring the fluid balance of an infant hospitalized with RSV. Which is a key nursing responsibility in this context?
A.Placing the child on a fluid-restricted diet to prevent overload.
B.Encouraging frequent, large-volume bottle feedings.
C.Strictly monitoring intake and output.
D.Administering diuretic medication to reduce lung secretions.
C.Strictly monitoring intake and output.
A nurse is caring for a newborn diagnosed with cystic fibrosis. Which initial finding in the neonatal period is a direct consequence of exocrine gland dysfunction in the small intestine?
A.Frequent, watery diarrhea
B.Intestinal obstruction from inspissated meconium
C.Biliary cirrhosis and portal hypertension
D.Failure to secrete digestive enzymes
B.Intestinal obstruction from inspissated meconium
A 5-year-old child is in the post-anesthesia care unit after a tonsillectomy. The nurse observes the child is swallowing frequently. What is the nurse's most appropriate initial action?
A.Administer a prescribed dose of acetaminophen for pain.
B.Offer the child a red popsicle to soothe the throat.
C.Inspect the posterior pharynx with a tongue depressor.
D.Place the child in a supine position to promote rest.
C.Inspect the posterior pharynx with a tongue depressor.
An infant rescued from a house fire has a pulse oximetry reading of 99%. Despite this reading, the infant appears lethargic and pale. The nurse should suspect which underlying issue?
A.Equipment malfunction
B.Severe anemia
C.Carbon monoxide poisoning
D.Atelectasis
C.Carbon monoxide poisoning
An exhausted infant displays a rhythmic, up-and-down motion of the head with each breath. The nurse recognizes this as head bobbing and understands it is a significant indicator of what condition?
A.Dyspnea
B.Pleural chest pain
C.Upper airway obstruction
D.Chronic hypoxemia
A.Dyspnea
A school-aged child with cystic fibrosis is admitted to the hospital with difficulty breathing, shallow respirations, chest pain, and anxiety. The nurse notes a low oxygen saturation level. These findings are most indicative of which complication?
A.Generalized obstructive emphysema
B.Pneumothorax
C.Exacerbation of pan-sinusitis
D.Chronic bronchial pneumonia
B.Pneumothorax
A parent asks why they should not give their 3-year-old child an over-the-counter cough and cold medication. The nurse's response should be based on the risk of what potential complication?
A.Masking the symptoms of a superinfection.
B.Overdose from acetaminophen.
C.Allergic reaction to the decongestant.
D.Rebound congestion from the nasal spray.
B.Overdose from acetaminophen.
A parent of a child with cystic fibrosis asks why their child's stools are often frothy, foul-smelling, and float. The nurse's best explanation is that these characteristics are due to:
A.An overgrowth of bacteria in the small intestine from chronic antibiotic use.
B.The undigested fat passing through the gastrointestinal tract.
C.Rapid intestinal transit time caused by abnormal mucus secretions.
D.Blockage of bile ducts, leading to an inability to process bilirubin.
B.The undigested fat passing through the gastrointestinal tract.
A nurse is caring for a child diagnosed with epiglottitis. Which of the following is an essential component of the care plan?
A.Maintain the child on NPO status.
B.Use restraints as needed to secure an IV line.
C.Offer clear liquids to maintain hydration.
D.Perform frequent oral temperature checks.
A.Maintain the child on NPO status.
A nurse is teaching the parents of a child with spasmodic croup about home care. Which of the following statements indicates the parents understand the instructions?
A.'If he has a coughing spell, we can take him into the bathroom with a hot shower running.'
B.'We will give him an adult dose of cough syrup before bed to prevent waking up.'
C.'If he starts coughing, we should make him lie flat on his back to open his airway.'
D.'We should keep the house warm and dry to prevent the cough from getting worse.'
A.'If he has a coughing spell, we can take him into the bathroom with a hot shower running.'
A nurse is providing discharge instructions to the parents of a child who had a myringotomy with tube placement. Which statement by the parent indicates a need for further teaching?
A.It's important that we keep the ears dry, so we will be careful during bath time.
B.I can give my child an over-the-counter decongestant to help with any stuffiness.
C.We should encourage the child to lie on his side.
D.I will call the doctor if the tubes fall out within the next month.
B.I can give my child an over-the-counter decongestant to help with any stuffiness.
A physician orders a sweat test for a 3-month-old infant suspected of having cystic fibrosis. Which result would be considered diagnostic for the condition?
A.Sodium concentration of 50 mEq/L
B.Chloride concentration less than 40 mEq/L
C.Positive genetic test for a single CFTR mutation
D.Chloride concentration greater than or equal to 60 mEq/L
D.Chloride concentration greater than or equal to 60 mEq/L
A 2-year-old child, who is not vaccinated, presents with a 1-week history of symptoms resembling a common cold. The child now has uncontrollable coughing spells that end in a characteristic high-pitched sound. The nurse recognizes these symptoms as typical of which stage of pertussis?
A.Convalescent phase
B.Incubation phase
C.Paroxysmal phase
D.Catarrhal phaseHint
C.Paroxysmal phase
A child's peak flow meter reading is 60% of their personal best, and they report waking up at night with a cough. According to the zone system, what is the priority action for the child to take?
A.Administer an extra dose of their inhaled corticosteroid
B.Use a short-acting bronchodilator
C.Continue with their routine treatment plan
D.Go to the emergency room immediately
B.Use a short-acting bronchodilator
Parents of a 4-month-old ask why their baby has had so many colds recently. The nurse's best explanation is that at this age:
A.The infant's surfactant levels are still insufficient for lung defense.
B.The funnel shape of the larynx traps more organisms than the adult cylinder shape.
C.Passive immunity from the mother has declined, and the infant's own immune system is still developing.
D.Infants primarily breathe through their mouths, increasing exposure.
E.Infant has not gotten their flu shot yet.
C.Passive immunity from the mother has declined, and the infant's own immune system is still developing.
A patient with confirmed RSV is being considered for antibiotic therapy. In which situation would the administration of antibiotics be appropriate?
A.As a prophylactic measure in all hospitalized infants.
B.When the patient develops a concurrent bacterial otitis media
C.If the patient's fever continues for more than 48 hours.Not quiteProlonged fever is common in viral illnesses like RSV and is not, by itself, an indication for starting antibiotics without evidence of a bacterial source.
D.To reduce the duration of the viral shedding period.
B.When the patient develops a concurrent bacterial otitis media
Which treatment modality for RSV is intended to open constricted airways, although its efficacy can be variable?
A.Bronchodilators
B.Cold, humidified O2
C.Corticosteroids
D.Antibiotics
A.Bronchodilators
A child with persistent asthma and seasonal allergies is prescribed a leukotriene modifier. The parent asks if this medication can replace their rescue inhaler during an asthma attack. What is the nurse's best response?
A.No, this is a controller medication for long-term management and not for acute situations.
B.Yes, it can be used if the rescue inhaler is not available.
C.No, this medication is only for seasonal allergies and has no effect on asthma.
D.Yes, it works faster than the rescue inhaler for allergy-induced asthma.
A.No, this is a controller medication for long-term management and not for acute situations.
A nurse observes an infant whose retractions have progressed from the subcostal area to the supraclavicular and suprasternal areas. How should the nurse interpret this clinical change?
A.The infant is experiencing a cardiac event.
B.The respiratory distress is worsening.
C.The infant's condition is improving.
D.The infant is developing pneumonia.
B.The respiratory distress is worsening.
A parent reports their child's asthma symptoms frequently worsen at night. The nurse should inquire about a history of which co-morbid condition that is strongly associated with nocturnal asthma?
A.Gastroesophageal reflux disease (GERD)
B.Exercise-induced bronchospasm
C.Atopic dermatitis (eczema)
D.Seasonal allergies (allergic rhinitis)
A.Gastroesophageal reflux disease (GERD)
A nurse is teaching a group of new parents about preventing acute otitis media (AOM) in their children. Which preventative measure is most supported by the provided material?
A.Scheduling a tonsillectomy if the child gets strep throat.
B.Ensuring the child receives the Pneumococcal Conjugate Vaccine (PCV13).
C.Administering over-the-counter decongestants during a cold.
D.Cleaning the external ear canal with hydrogen peroxide daily.
B.Ensuring the child receives the Pneumococcal Conjugate Vaccine (PCV13).
A nurse is preparing a meal tray for a 6-year-old child who is 12 hours post-tonsillectomy. Which item is most appropriate to include?
A.A glass of orange juice.
B.A small bowl of chicken noodle soup.
C.A cup of vanilla ice cream.
D.A grape-flavored popsicle.
C.A cup of vanilla ice cream.
A parent asks why their 2-year-old child, who has had five episodes of strep throat in the past year, cannot have a tonsillectomy. What is the best explanation the nurse can provide?
A.The procedure is too painful for children under the age of three.
B.There is an increased risk of significant blood loss and potential for tissue regrowth in very young children.
C.The child's immune system is not developed enough to handle the surgery.
D.Children younger than three are not eligible for the necessary general anesthesia.
B.There is an increased risk of significant blood loss and potential for tissue regrowth in very young children.
A patient arrives in the emergency department with an acute anaphylactic reaction. The nurse would anticipate which cardiovascular finding?
A.Normal blood pressure and bradycardia
B.Hypertension and a normal heart rate
C.Hypertension and bradycardia
D.Hypotension and tachycardia
D.Hypotension and tachycardia
A child in the hospital with spasmodic croup is ordered nebulized epinephrine. The nurse understands this medication is primarily used for what reason?
A.To cause rapid mucosal vasoconstriction and open the airway.
B.To treat the underlying viral infection.
C.To sedate the child and decrease anxiety.
D.To reduce fever and inflammation over several hours.
A.To cause rapid mucosal vasoconstriction and open the airway.