NCLEX Practice Questions
With Answers
A 10-month-old child has cold symptoms. The mother asks how she can
clear infant's nose. Which of the following would be the nurse's best
recommendation?
a. use a cool air vaporizer with plain water
b. use saline nose drops and then a bulb syringe
c. blow into the child's mouth to clear the nose
d. administer a nonprescription vasoconstrictive nose spray. - correct
answerb - although a cool air vaporizer may be recommended to
humidify the environment, using saline nose drops and then a bulb
syringe before meals and at nap and bed times will allow the child to
breathe more easily. Saline helps to loosen secretions and keep the
mucous membranes moist. The bulb syringe then gently aids in
removing the loosened secretions. Blowing into the child's mouth to
clear the nose introduces more organisms to the child. A
nonprescription vasoconstrictive nasal spray is not recommended for
infants because if the spray in used for longer than 3 days a rebound
effect with increased inflammation occurs.
,A 10-month-old child with recurrent otitis media is brought to the clinic
for evaluation. To help determine the cause of the child's condition, the
nurse should ask the parents:
a) "Does water ever get into the baby's ears during shampooing?"
b) "Do you give the baby a bottle to take to bed?"
c) "Have you noticed a lot of wax in the baby's ears?"
d) "Can the baby combine two words when speaking?" - correct
answerb - In a young child, the eustachian tube is relatively short, wide,
and horizontal, promoting drainage of secretions from the nasopharynx
into the middle ear. Therefore, asking if the child takes a bottle to bed
is appropriate because drinking while lying down may cause fluids to
pool in the pharyngeal cavity, increasing the risk of otitis media. Asking
if the parent noticed earwax, or cerumen, in the external ear canal is
incorrect because wax doesn't promote the development of otitis
media. During shampooing, water may become trapped in the external
ear canal by large amounts of cerumen, possibly causing otitis external
(external ear inflammation) as opposed to internal ear inflammation.
Asking if the infant can combine two words is incorrect because a 10-
month-old child isn't expected to do so.
A 10-year-old child diagnosed with acute glomerulonephritis is
admitted to the pediatric unit. The nurse should ensure that which
action is a part of the child's care?
a) Taking vital signs every 4 hours and obtaining daily weight
b) Obtaining a blood sample for electrolyte analysis every morning
c) Checking every urine specimen for protein and specific gravity
d) Ensuring that the child has accurate intake and output and eats a
high-protein diet - correct answera) CORRECT ANSWER Taking vital
signs every 4 hours and obtaining daily weight
Reason: Because major complications — such as hypertensive
encephalopathy, acute renal failure, and cardiac decompensation —
,can occur, monitoring vital signs (including blood pressure) is an
important measure for a child with acute glomerulonephritis. Obtaining
daily weight and monitoring intake and output also provide evidence of
the child's fluid balance status. Sodium and water restrictions may be
ordered depending on the severity of the edema and the extent of
impaired renal function. Typically, protein intake remains normal for
the child's age and is only increased if the child is losing large amounts
of protein in the urine. Checking urine specimens for protein and
specific gravity and daily monitoring of serum electrolyte levels may be
done, but their frequency is determined by the child's status. These
actions are less important nursing measures in this situation.
A 10-year-old with glomerulonephritis reports a headache and blurred
vision. The nurse should immediately:
a) Put the client to bed.
b) Obtain the child's blood pressure.
c) Notify the physician.
d) Administer acetaminophen (Tylenol). - correct answerb) CORRECT
ANSWER Obtain the child's blood pressure.
Reason: Hypertension occurs with acute glomerulonephritis. The
symptoms of headache and blurred vision may indicate an elevated
blood pressure. Hypertension in acute glomerulonephritis occurs due to
the inability of the kidneys to remove fluid and sodium; the fluid is
reabsorbed, causing fluid volume excess. The nurse must verify that
these symptoms are due to hypertension. Calling the physician before
confirming the cause of the symptoms would not assist the physician in
his treatment. Putting the client to bed may help treat an elevated
blood pressure, but first the nurse must establish that high blood
pressure is the cause of the symptoms. Administering Tylenol for high
blood pressure is not recommended.
, A 16-year-old academically gifted boy is about to graduate from high
school early, because he has completed all courses needed to earn a
diploma. Within the last 3 months, he has experienced panic attacks
that have forced him to leave classes early and occasionally miss a day
of school. He is concerned that these attacks may hinder his ability to
pursue a college degree. What would be the best response by the
school nurse who has been helping him deal with his panic attacks?
a) "It is natural to be worried about going into a new environment. I am
sure with your abilities you will do well once you get settled."
b) "You are putting too much pressure on yourself. You just need to
relax more and things will be alright."
c) "It might be best for you to postpone going to college. You need to
get these panic attacks controlled first."
d) "It sounds like you have a real concern about transitioning to college.
I can refer - correct answerd) CORRECT ANSWER "It sounds like you
have a real concern about transitioning to college. I can refer you to a
health care provider for assessment and treatment."
Reason: The client's concerns are real and serious enough to warrant
assessment by a physician rather than being dismissed as trivial.
Though he is very intelligent, his intelligence cannot overcome his
anxiety. In fact, his anxiety is likely to interfere with his ability to
perform in college if no assessment and treatment are received. Just
postponing college is likely to increase rather than lower the client's
anxiety, because it does not address the panic he is experiencing.
A 16-year-old primigravida at 36 weeks' gestation who has had no
prenatal care experienced a seizure at work and is being transported to
the hospital by ambulance. Which of the following should the nurse do
upon the client's arrival?
a) Position the client in a supine position.
b) Auscultate breath sounds every 4 hours.
With Answers
A 10-month-old child has cold symptoms. The mother asks how she can
clear infant's nose. Which of the following would be the nurse's best
recommendation?
a. use a cool air vaporizer with plain water
b. use saline nose drops and then a bulb syringe
c. blow into the child's mouth to clear the nose
d. administer a nonprescription vasoconstrictive nose spray. - correct
answerb - although a cool air vaporizer may be recommended to
humidify the environment, using saline nose drops and then a bulb
syringe before meals and at nap and bed times will allow the child to
breathe more easily. Saline helps to loosen secretions and keep the
mucous membranes moist. The bulb syringe then gently aids in
removing the loosened secretions. Blowing into the child's mouth to
clear the nose introduces more organisms to the child. A
nonprescription vasoconstrictive nasal spray is not recommended for
infants because if the spray in used for longer than 3 days a rebound
effect with increased inflammation occurs.
,A 10-month-old child with recurrent otitis media is brought to the clinic
for evaluation. To help determine the cause of the child's condition, the
nurse should ask the parents:
a) "Does water ever get into the baby's ears during shampooing?"
b) "Do you give the baby a bottle to take to bed?"
c) "Have you noticed a lot of wax in the baby's ears?"
d) "Can the baby combine two words when speaking?" - correct
answerb - In a young child, the eustachian tube is relatively short, wide,
and horizontal, promoting drainage of secretions from the nasopharynx
into the middle ear. Therefore, asking if the child takes a bottle to bed
is appropriate because drinking while lying down may cause fluids to
pool in the pharyngeal cavity, increasing the risk of otitis media. Asking
if the parent noticed earwax, or cerumen, in the external ear canal is
incorrect because wax doesn't promote the development of otitis
media. During shampooing, water may become trapped in the external
ear canal by large amounts of cerumen, possibly causing otitis external
(external ear inflammation) as opposed to internal ear inflammation.
Asking if the infant can combine two words is incorrect because a 10-
month-old child isn't expected to do so.
A 10-year-old child diagnosed with acute glomerulonephritis is
admitted to the pediatric unit. The nurse should ensure that which
action is a part of the child's care?
a) Taking vital signs every 4 hours and obtaining daily weight
b) Obtaining a blood sample for electrolyte analysis every morning
c) Checking every urine specimen for protein and specific gravity
d) Ensuring that the child has accurate intake and output and eats a
high-protein diet - correct answera) CORRECT ANSWER Taking vital
signs every 4 hours and obtaining daily weight
Reason: Because major complications — such as hypertensive
encephalopathy, acute renal failure, and cardiac decompensation —
,can occur, monitoring vital signs (including blood pressure) is an
important measure for a child with acute glomerulonephritis. Obtaining
daily weight and monitoring intake and output also provide evidence of
the child's fluid balance status. Sodium and water restrictions may be
ordered depending on the severity of the edema and the extent of
impaired renal function. Typically, protein intake remains normal for
the child's age and is only increased if the child is losing large amounts
of protein in the urine. Checking urine specimens for protein and
specific gravity and daily monitoring of serum electrolyte levels may be
done, but their frequency is determined by the child's status. These
actions are less important nursing measures in this situation.
A 10-year-old with glomerulonephritis reports a headache and blurred
vision. The nurse should immediately:
a) Put the client to bed.
b) Obtain the child's blood pressure.
c) Notify the physician.
d) Administer acetaminophen (Tylenol). - correct answerb) CORRECT
ANSWER Obtain the child's blood pressure.
Reason: Hypertension occurs with acute glomerulonephritis. The
symptoms of headache and blurred vision may indicate an elevated
blood pressure. Hypertension in acute glomerulonephritis occurs due to
the inability of the kidneys to remove fluid and sodium; the fluid is
reabsorbed, causing fluid volume excess. The nurse must verify that
these symptoms are due to hypertension. Calling the physician before
confirming the cause of the symptoms would not assist the physician in
his treatment. Putting the client to bed may help treat an elevated
blood pressure, but first the nurse must establish that high blood
pressure is the cause of the symptoms. Administering Tylenol for high
blood pressure is not recommended.
, A 16-year-old academically gifted boy is about to graduate from high
school early, because he has completed all courses needed to earn a
diploma. Within the last 3 months, he has experienced panic attacks
that have forced him to leave classes early and occasionally miss a day
of school. He is concerned that these attacks may hinder his ability to
pursue a college degree. What would be the best response by the
school nurse who has been helping him deal with his panic attacks?
a) "It is natural to be worried about going into a new environment. I am
sure with your abilities you will do well once you get settled."
b) "You are putting too much pressure on yourself. You just need to
relax more and things will be alright."
c) "It might be best for you to postpone going to college. You need to
get these panic attacks controlled first."
d) "It sounds like you have a real concern about transitioning to college.
I can refer - correct answerd) CORRECT ANSWER "It sounds like you
have a real concern about transitioning to college. I can refer you to a
health care provider for assessment and treatment."
Reason: The client's concerns are real and serious enough to warrant
assessment by a physician rather than being dismissed as trivial.
Though he is very intelligent, his intelligence cannot overcome his
anxiety. In fact, his anxiety is likely to interfere with his ability to
perform in college if no assessment and treatment are received. Just
postponing college is likely to increase rather than lower the client's
anxiety, because it does not address the panic he is experiencing.
A 16-year-old primigravida at 36 weeks' gestation who has had no
prenatal care experienced a seizure at work and is being transported to
the hospital by ambulance. Which of the following should the nurse do
upon the client's arrival?
a) Position the client in a supine position.
b) Auscultate breath sounds every 4 hours.
