Pediatric Success - NCLEX
Practice Q's (2025)
comprehensive questions
and verified detailed
solutions ( MULTIPLE
CHOICES) |100%
CORRECT!!
1.
The mother of a 3-week-old tells the nurse she is residing in a
homeless shelter and
is concerned about his mild cough, poor appetite, low-grade fever,
weight loss, and
fussiness over the last 2 weeks. Which nursing intervention would
be the nurse's
highest priority?
1. Weigh the baby to have an accurate weight using standard
precautions.
2. Reassure the mother that the baby may only have a cold,
which can last a few
weeks.
,3. Immediately initiate droplet face-mask precautions, and isolate
the infant.
4. Take a rectal temperature while completing the assessment
using standard
precautions. - ✔✔ANSW✔✔..Answer:
3. Immediately initiate droplet face-mask precautions, and isolate
the infant.
Rationale:
1. Weighing the child would be important but
not the priority when concerned about an
infectious cause. Initiating droplet precau-
tions to prevent infecting others would be a
priority, then weighing the infant.
2. The symptoms are not suggestive of a cold
but something more serious. Infants do not
usually lose weight, nor are they irritable
with a simple cold.
3.
Children with tuberculosis may have a
history of living in a crowded home or
could be homeless. Other symptoms
may include a cough, cold symptoms,
low-grade fever, irritability, poor
appetite, and exposure to a person
with tuberculosis. Initiation of droplet
precautions and isolation of the infant
would be warranted in this situation.
4. Taking the infant's temperature is important, but initiating
droplet precautions
would be the priority.
TEST-TAKING HINT:
The test taker should be
, highly suspicious of tuberculosis given the family and patient
history. Health-care personnel need to be vigilant to contain and
prevent further spread of communicable
diseases. This child could have meningitis, which would also
require isolation and
respiratory precautions.
2.
Which would be the priority nursing intervention for a newly
admitted child with Kawasaki disease?
1. Continuous cardiovascular and oxygen-saturation monitoring.
2. Vital signs every 4 hours until stable.
3. Strict intake and output monitoring hourly.
4. Begin aspirin therapy after fever has resolved. -
✔✔ANSW✔✔..Answer:
1. Continuous cardiovascular and oxygen-saturation monitoring.
Rationale:
1. Cardiovascular manifestations of
Kawasaki disease are the major complications in pediatric
patients. Continuous cardiac monitoring is required to alert
the nurse of any cardiovascular complications. Decreased oxygen
saturation
and respiratory changes have been
shown to be early indicators of potential complications.
2. Vital signs would be taken every 1 to
2 hours until stable on a new admission
with Kawasaki disease.
3. Strict intake and output is very important,
but because the major complications with
Kawasaki disease are cardiovascular, contin-
uous cardiac monitoring is the priority.
4. High-dose aspirin therapy is begun and
continued until the child has been afebrile
for 48 to 72 hours; then the child is placed
Practice Q's (2025)
comprehensive questions
and verified detailed
solutions ( MULTIPLE
CHOICES) |100%
CORRECT!!
1.
The mother of a 3-week-old tells the nurse she is residing in a
homeless shelter and
is concerned about his mild cough, poor appetite, low-grade fever,
weight loss, and
fussiness over the last 2 weeks. Which nursing intervention would
be the nurse's
highest priority?
1. Weigh the baby to have an accurate weight using standard
precautions.
2. Reassure the mother that the baby may only have a cold,
which can last a few
weeks.
,3. Immediately initiate droplet face-mask precautions, and isolate
the infant.
4. Take a rectal temperature while completing the assessment
using standard
precautions. - ✔✔ANSW✔✔..Answer:
3. Immediately initiate droplet face-mask precautions, and isolate
the infant.
Rationale:
1. Weighing the child would be important but
not the priority when concerned about an
infectious cause. Initiating droplet precau-
tions to prevent infecting others would be a
priority, then weighing the infant.
2. The symptoms are not suggestive of a cold
but something more serious. Infants do not
usually lose weight, nor are they irritable
with a simple cold.
3.
Children with tuberculosis may have a
history of living in a crowded home or
could be homeless. Other symptoms
may include a cough, cold symptoms,
low-grade fever, irritability, poor
appetite, and exposure to a person
with tuberculosis. Initiation of droplet
precautions and isolation of the infant
would be warranted in this situation.
4. Taking the infant's temperature is important, but initiating
droplet precautions
would be the priority.
TEST-TAKING HINT:
The test taker should be
, highly suspicious of tuberculosis given the family and patient
history. Health-care personnel need to be vigilant to contain and
prevent further spread of communicable
diseases. This child could have meningitis, which would also
require isolation and
respiratory precautions.
2.
Which would be the priority nursing intervention for a newly
admitted child with Kawasaki disease?
1. Continuous cardiovascular and oxygen-saturation monitoring.
2. Vital signs every 4 hours until stable.
3. Strict intake and output monitoring hourly.
4. Begin aspirin therapy after fever has resolved. -
✔✔ANSW✔✔..Answer:
1. Continuous cardiovascular and oxygen-saturation monitoring.
Rationale:
1. Cardiovascular manifestations of
Kawasaki disease are the major complications in pediatric
patients. Continuous cardiac monitoring is required to alert
the nurse of any cardiovascular complications. Decreased oxygen
saturation
and respiratory changes have been
shown to be early indicators of potential complications.
2. Vital signs would be taken every 1 to
2 hours until stable on a new admission
with Kawasaki disease.
3. Strict intake and output is very important,
but because the major complications with
Kawasaki disease are cardiovascular, contin-
uous cardiac monitoring is the priority.
4. High-dose aspirin therapy is begun and
continued until the child has been afebrile
for 48 to 72 hours; then the child is placed
