Pediatric NCLEX Questions

Answers and Rationale

1) B
- Whereas ipecac is administered to induce vomiting in certain poisoning situations, it is not recommended as the
initial treatment in the hospital setting for ingestion of salicylates. This is because ipecac does not totally remove the
poison from the child's system. In this situation, the child is conscious and the ingested substance (aspirin) would not
damage the esophagus or lungs from vomiting. owever, activated charcoal would be prescribed as an antidote in
this poisoning situation, because its action is to absorb ingested to!ic substances and thus decrease absorption.
"ptions # and $ are unrelated to treatment for this occurrence.
2) C
- %nresponsiveness may be an indication that the child is e!periencing hearing loss. & child who has a history of cleft
palate should be routinely chec'ed for hearing loss. "ptions ( and $ are unrelated to cleft palate after repair. "ption
& is normal behavior for a preschool child. )any preschoolers with vivid imaginations have imaginary friends.
3) D
- When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication*
therefore, neurovascular chec's including circulation, sensation, and motion should be done at least every + hours.
,evel of pain is an important postoperative assessment, but circulatory status is more important. &ssessment of
fle!ion and e!tension of the lower e!tremities is a component of option $, which includes chec'ing motion. ,ogrolling
is performed by nurses.
4) B
- $uring the first few hours after a cast is applied, the chief concern is swelling that may cause the cast to act as a
tourni-uet and obstruct circulation, resulting in compartment syndrome. Therefore, circulatory assessment is the
priority. .levating the head of the bed of a child in a hip spica cast would cause discomfort. %sing pillows to abduct
the hips is not necessary because a hip spica cast immobili/es the hip and 'nee. Turning the child side to side at
least every + hours is important because it allows the body cast to dry evenly and prevents complications related to
immobility* however, it is not a higher priority than chec'ing circulation.
5) C
- &cetylcysteine ()ucomyst) is the antidote for acetaminophen overdose. It is administered orally or via nasogastric
tube in a diluted form with water, 0uice, or soda. It can also be administered intravenously. 1itamin 2 is the antidote for
warfarin (#oumadin). 3rotamine sulfate is the antidote for heparin. 4uccimer (#hemet) is used in the treatment of
lead poisoning.
) D
- The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and
warrants physician notification. "ptions &, (, and # are inaccurate interpretations.
!) A
- The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal
infant, and it normally closes by 5+ to 56 months of age. The posterior fontanel closes by + to 7 months of age. &
bulging or tense fontanel may result from crying or increased I#3. 8oting a bulging fontanel when the infant cries is a
normal finding that should be documented and monitored. It is not necessary to notify the physician. "ptions ( and #
are inappropriate actions.
") C
- The normal respiratory rate for a 7-year-old child is appro!imately +9 to 79 breaths per minute. (ecause the
respiratory rate is normal, options &, (, and $ are unnecessary actions. The nurse would document the findings.
#) A
- :ollowing tonsillectomy, clear, cool li-uids should be administered. #itrus, carbonated, and e!tremely hot or cold
li-uids need to be avoided because they may irritate the throat. ;ed li-uids need to be avoided because they give the
appearance of blood if the child vomits. )il' and mil' products (pudding) are avoided because they coat the throat
and cause the child to clear the throat, thus increasing the ris' of bleeding.
1$) C
- %se the formula to determine the dosage parameters. #onvert pounds to 'ilograms by dividing weight by +.+.
Therefore, 559 lb. divided by +.+ < =9 'g.$osage parameters> 9.5 mg?'g?dose =9 'g < = mg9.+ mg?'g?dose =9 'g <
59 mg$osage is within the safe dosage range.
11) C
- The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal
fluid. #ommon signs include nuchal rigidity, lethargy, and vomiting. & red swollen testicle may be indicative of orchitis.
&lthough this complication appears to cause most concern among parents, it is not the most common complication.
&lthough mumps is one of the leading causes of unilateral nerve deafness, it does not occur fre-uently. )uscular
pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.
12) B
- The nursing care of a child with ;)4: will include the administration of do!ycycline. &n alternative medication is
chloramphenicol. &mphotericin ( is used for fungal infections. @anciclovir is used to treat cytomegalovirus.
&mantadine is used to treat 3ar'inson's disease.
13) B
- The hallmar' symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total
surgical removal of the tumor without residual neurological damage. (efore surgery, the child's head will be shaved,
although every effort is made to shave only as much hair as is necessary. ;adiation therapy is avoided in children
younger than 7 years of age due to the to!ic side effects on the developing brain, particularly in very young children.
14) D
- .$T& is a chelating agent that is used to treat lead poisoning. 4odium bicarbonate may be used in salicylate
poisoning. Ipecac syrup may be prescribed for use in the hospital setting but would not be used to treat lead
poisoning. &ctivated charcoal is used to decrease absorption in certain poisoning situations.
15) D
- @luten is found primarily in the grains of wheat and rye. #orn and rice become substitute foods. @luten is added to
many foods as hydroly/ed vegetable protein that is derived from cereal grains, therefore labels need to be read. #orn
and rice as well as vegetables are acceptable in a gluten-free diet. )any pasta products contain gluten. @rains are
fre-uently added to processed foods for thic'ness or fillers.
1) B
- &dding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to
gradually ad0ust to the changing water temperature and will not e!perience chilling. &lcohol is to!ic and
contraindicated for tepid sponge or tub baths. To achieve the best cooling results, the water temperature should be at
least + degrees lower than the child's body temperature. The child should be in a tepid tub bath for +9 to 79 minutes
to achieve ma!imum results.
1!) A
- The incision should be rinsed with sterile water after every feeding. ;ubbing alters the integrity of the suture line.
;ather, the incision should be patted or dabbed. The purpose of the ,ogan bar is to maintain the integrity of the
suture line. ;emoving the ,ogan bar on the first postoperative day would increase tension on the surgical incision.
1") D
- .levating the head will decrease the chance of cerebrospinal fluid collecting in the cranial cavity. The infant needs to
be prone for several days to decrease the pressure on the surgical site on the bac'. (inders and a baby seat should
not be used because of the pressure they would e!ert on the surgical site.
1#) C
- Intracranial pressure and encephalopathy are ma0or problems associated with ;eye's syndrome. 3rotein is not
present in the urine. ;eye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this
disease.
2$) B
& complication of pneumococcal pneumonia is pleural effusion, so the respiratory status of the child needs to be
monitored. &ntibiotic therapy is not started until cultures are obtained. The child should not be allowed to be around
other children at this time. & chest radiograph needs to be prescribed by the physician.