NCLEX RN Registered Nurses Quiz | Practice Test 02
1 >>A client is attending a newborn discharge class and asks a nurse about the bump on the infant's head. Upon assessment, the neonate has a large, diffuse swelling on the left occiput that crosses the sagittal suture line. The nurse should explain to the mother that: Select all that apply. ?
(A) This is a collection of blood under the skull bone of the infant.
(B) It is edematous swelling that overlies the periosteum.
(C) It leads to hyperbilirubinemia in the infant.
(D) It will require no treatment to resolve.
2 >>A child with status post-Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first? ?
(A) Call the surgeon immediately.
(B) Assess patency of the urinary catheter.
(C) Administer pain medication as ordered.
(D) Complete a neurological assessment.
3 >>What assessment findings should a nurse expect in a child with acute post-streptococcal glomerulonephritis? Select all that apply. ?
(A) Severe hematuria.
(B) Pallor.
(C) Decreased urine specific gravity.
(D) Weight gain.
4 >>In doing a child's admission assessment, which signs and symptoms should a nurse recognize as most likely related to rheumatic fever? ?
(A) Vomiting and diarrhea.
(B) Arthralgia and muscle weakness.
(C) Conjunctivitis and red, cracked lips.
(D) Bradycardia and hypotension.
5 >>When preparing an intramuscular injection for a 1-week-old infant, which needle would be the most appropriate for the nurse to select? ?
(A) 18 G, 7 /8 inch.
(B) 21 G, 1 inch.
(C) 25 G, 5 /8 inch.
(D) 25 G, 11 /2 inch.
6 >>A young child diagnosed with iron-deficiency anemia is prescribed a liquid iron supplement. A nurse provides the parents with instructions on administration and should be certain to advise them that: ?
(A) The medication should be given along with the child's morning cereal breakfast.
(B) The child may experience some pale-colored stools.
(C) The child should be permitted to sip the medication from a medicine cup.
(D) The medication can be mixed with a small amount of fruit juice.
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7 >>A child is receiving chemotherapy for the treatment of osteosarcoma. Which morning laboratory result must a nurse report immediately to the physician? ?
(A) Absolute neutrophil count of 1200.
(B) Platelet count of 150,000.
(C) Urine dipstick positive for heme.
(D) WBC count of 4500.
8 >>Which statement made by the mother of a child with cystic fibrosis should indicate to a nurse that the mother is in need of further teaching regarding the administration of pancreatic enzymes? ?
(A) "I'll crush the capsules and mix with my child's food."
(B) "The capsule can be broken and its contents sprinkled onto food."
(C) "I may need to give more enzymes with larger meals."
(D) "I will administer the enzymes 30 minutes after the meal."
9 >>A nurse is working with a nursing student in the care of a young child status post-appendectomy. The student checks the current order of IV gentamicin and discovers the ordered dose is above the safe dose range based on the child's weight. What should be the nurse's first action? ?
(A) Check the child's recent lab work.
(B) Contact the physician.
(C) Order a hearing test.
(D) Obtain an order for BUN and creatinine.
10 >>A child with type 1 diabetes is being prepared for discharge from a hospital. What should a nurse include as part of the teaching regarding diabetes care? ?
(A) Expect hypoglycemic episodes to always occur after meals.
(B) Insulin dosage may need to be decreased during sports activities.
(C) The child should not self-administer injections until the teen years.
(D) Insulin should never be administered during febrile illnesses.
11 >>An LVN/LPN from an orthopedic unit is floated to a child health unit. In creating assignments, which child should the charge nurse avoid assigning to the LVN/LPN? ?
(A) A 10-year-old in traction for a fractured femur.
(B) An 8-year-old child with Legg-Calv�-Perthes disease.
(C) A 4-year-old with osteogenesis imperfecta.
(D) A teenager receiving chemotherapy for osteosarcoma.
12 >>A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse? ?
(A) Capillary refill time of 2 seconds.
(B) Transient mottling of the skin.
(C) Irregular respirations.
(D) Negative Babinski reflex.
13 >>The parent of a young child phones an advice nurse to report that the child is ill. The child has a reddish pinpoint rash most concentrated in the axilla and groin areas, a high fever, flushed cheeks, and abdominal pain. The parent also reports that the child's tongue is dark red with white spots. A nurse should recognize these symptoms as indicative of which infection? ?
(A) Mumps.
(B) Measles.
(C) Scarlet fever.
(D) Varicella.
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14 >>An 80-year-old client is being discharged home after having surgery to d�bride a chronic venous ulcer on the right ankle. Which referral is most appropriate for DH, the charge nurse, to make? ?
(A) Hospice.
(B) Home health.
(C) Physical therapist.
(D) Cardiac rehabilitation.
15 >>Which would be an abnormal finding when doing a well-child checkup on a 1-week-old infant? ?
(A) An audible "clunk" during the Ortolani test.
(B) Symmetrical gluteal folds when the infant is held upright.
(C) Negative Barlow test.
(D) Symmetrical knee height when the infant is supine.
16 >>Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air? ?
(A) Allow the child to sit in a position of comfort.
(B) Provide small amounts of liquid orally via a syringe.
(C) Inspect the child's nares to assess degree of swelling.
(D) Apply 100% oxygen via mask.
17 >>A child recovering from abdominal surgery removes the nasogastric tube accidentally. A nurse replaces the nasogastric tube and places it to low wall suction. Two hours later, the nurse discovers that there is no drainage from the tube. What should be the nurse's first action? ?
(A) Ask the child to change position.
(B) Place an urgent call to the surgeon.
(C) Flush the tube with 10 mL of sterile water.
(D) Check the suction mechanism and settings.
18 >>A charge nurse is seated in front of a bank of cardiac monitors on a pediatric unit. There are four children receiving cardiac monitoring. Which finding should the charge nurse communicate at once to the child's nurse? ?
(A) A heart rate of 50 in a 15-year-old adolescent who is sleeping.
(B) A heart rate of 190 in a 1-month-old infant who is crying.
(C) A heart rate of 160 in a 2-year-old child who is walking in the hallway.
(D) A heart rate of 75 in a 5-year-old child who is watching television.
19 >>A school-age child visits a school nurse and states that a family member has been behaving inappropriately by touching the child near the groin area. What should be the school nurse's priority action? ?
(A) Make a report to the proper child protective authorities as mandated by law.
(B) Contact the child's parents to share what the child has reported.
(C) Question the child to determine all of the details of the inappropriate touching.
(D) Provide the child with a safe and calm environment in which to continue the discussion.
20 >>Which child would be the best roommate for a 9-yearold child with myelodysplasia who is hospitalized for a foot infection? ?
(A) A 13-year-old with juvenile idiopathic arthritis.
(B) A 10-year-old with a fractured femur.
(C) An 8-year-old status post-appendectomy.
(D) A 6-year-old with bacterial meningitis.
21 >>A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply. ?
(A) Advancing diet as tolerated.
(B) Encouraging coughing to clear the throat.
(C) Monitoring PT and PTT.
(D) Administering pain medication around the clock.
22 >>A nurse is caring for a child newly diagnosed with congenital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is: ?
(A) Audible lung crackles.
(B) Increased heart rate.
(C) Weight gain.
(D) Generalized edema.
23 >>When teaching a class on home safety to new parents, on which type of exposure should a nurse focus as the primary cause of lead poisoning in children? ?
(A) Ingesting paint dust or chips from an old home.
(B) Having a parent who works near lead products.
(C) Riding in a car that uses leaded gasoline.
(D) Chewing on pencils with lead tips.
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24 >>A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation? ?
(A) Getting a meningitis vaccine is the only way to guarantee prevention.
(B) Refraining from sharing food and drinks is a good way to prevent meningitis infection.
(C) Avoiding team sports is one way to stop the spread of meningitis infection.
(D) Meningitis prevention methods should be employed whenever children are in crowds.
25 >>When providing anticipatory guidance to the parents of a child with hemophilia, a nurse should stress that: ?
(A) Active range-of-motion exercise should be used to treat sore joints.
(B) Aspirin should be given for minor bumps and bruises.
(C) Warm compresses should be applied to wounds to promote circulation.
(D) A soft toothbrush should be used to promote oral health.
26 >>When providing client teaching to the caregivers of a young child with sickle cell disease, a nurse should stress that: ?
(A) The child's diet should include whole grains and leafy green vegetables.
(B) Immunizations should be delayed until the child enters school.
(C) There is a 50% chance that the child's future offspring will have sickle cell anemia.
(D) The parents should request IV Demerol if the child is hospitalized with pain crisis.
27 >>A school nurse advises the dietary staff that a special lunch tray must be created for a student who has celiac disease. What recommendation should the nurse provide to the dietary staff? ?
(A) Make sure the student has a whole-grain bread roll each day.
(B) The child may have cake if the staff is celebrating someone's birthday.
(C) The child's pizza should be topped with a variety of vegetables.
(D) Beans and rice are suitable side dishes for this student.
28 >>An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant's dehydration is severe? ?
(A) The infant is lethargic with a urinary output of less than 1 mL/kg/hr.
(B) The infant has weak pulses, poor skin turgor, and cool, mottled skin.
(C) The infant has warm skin, increased pulse, and capillary refill of 2 seconds.
(D) The infant is irritable, with dry mucous membranes and increased respirations.
29 >>When visiting the home of a school-age child who is dying, what would be the best action by a hospice nurse? ?
(A) Speak softly (whisper) when speaking in the child's presence.
(B) Provide as little interaction with the child as possible.
(C) Avoid correcting the child who is in denial about dying.
(D) Rely on the parents for pain assessment.
30 >>A nurse is preparing to administer an unpleasant-tasting liquid medication to a toddler. What is the best method for administering this medication? ?
(A) Mix the medication with a cup of ice cream to mask the taste.
(B) Ask the child to choose between two types of fluids as a chaser.
(C) Request the parents hold the child firmly so the nurse can place the medication into the mouth.
(D) Offer the child a toy out of the toy box as a reward if the child agrees to take the medication.
31 >>A nursing student prepares to administer eyedrops to a young child. What action by the nursing student should cause a registered nurse to intervene? ?
(A) The student positions the child supine with head extended.
(B) After administration, the student asks the child to close eyes and move them around.
(C) The student schedules medication administration to occur just before lunchtime.
(D) Prior to administration, the student pulls the lower lid down, forming a sac.
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32 >>A school nurse is creating an informational brochure for parents regarding the treatment of head lice. What form of treatment should the nurse caution against? ?
(A) Applying repeated doses of permethrin for as long as it takes until the infestation clears.
(B) Washing all clothing and linens in hot water followed by drying them in a hot dryer.
(C) Wearing gloves when washing the child's hair or inspecting for nits.
(D) Removing nits daily from the child's hair with a finetooth comb.
13 >>The parents of a newborn infant ask a nurse how to prevent future ear infections. What is the best advice the nurse should provide these parents? ?
(A) Avoid crowds during the winter months.
(B) Allow the baby to bottle-feed in the supine position.
(C) Make sure the baby receives the DTaP vaccine as scheduled.
(D) Continue breastfeeding as close to the baby's first birthday as possible.
34 >>A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions? Select all that apply. ?
(A) Complete a neurological assessment.
(B) Place the child in the supine position.
(C) Administer the antiemetic as ordered.
(D) Complete a pain assessment.
35 >>A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming nurses calls to say, "Sorry, I'll be a few minutes late since I have a child home ill with the chickenpox." What type of assignment would be most acceptable for the nurse who will be late? ?
(A) Any assignment is fine as long as the nurse wears a mask.
(B) The nurse needs an assignment that does not include children with neutropenia.
(C) The nurse should not be given an assignment and should be called off.
(D) Any care assignment is acceptable, without restrictions.
36 >>A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse? ?
(A) Tachypnea.
(B) Scattered rhonchi.
(C) Expiratory grunt.
(D) Abdominal breathing.
37 >>While suctioning a child with a tracheostomy tube in place, a nurse discovers that the suction catheter will not advance inside the tracheostomy tube and the child is becoming pale and anxious, with noticeable suprasternal retractions. What should be the nurse's priority action? ?
(A) Change the tracheostomy tube at once.
(B) Instill normal saline into the tracheostomy tube and attempt suctioning again.
(C) Obtain a pulse oximetry reading.
(D) Auscultate lung sounds.
38 >>While preparing for an admission, a nurse hears the alarm sound on the cardiac monitor of a child in the next bed. The nurse views the screen and sees what appears to be ventricular fibrillation. What is the best initial action by the nurse? ?
(A) Call out for help.
(B) Assess the child.
(C) Begin chest compressions.
(D) Press the "Code Blue" button.
39 >>Which response to hospitalization is a nurse most likely to observe in a 4-year-old child? ?
(A) Fearfulness of loud noises and sudden movements.
(B) Frequent crying outbursts and agitation.
(C) Urinary frequency and fear of mutilation.
(D) Boredom or loneliness.
40 >>A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child's care? Select all that apply. ?
