NCLEX RN (NEXT GENERATION FORMART) Actual
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1. A 5-year-old child presents with lethargy, increased work
of breathing, and pale color. The primary assessment
reveals that the airway is open and the respiratory rate is
30/min, with crackles heard on auscultation. The cardiac
monitor shows sinus tachycardia at a rate of 165/min. The
pulse oximeter displays an oxygen saturation of 95% and
a pulse rate of 93/min. On the basis of this information,
which of the following provides the best interpretation of
the oxygen saturation of 95% by pulse oximetry?
,A. Reliable; no supplementary oxygen is indicated B.
Reliable; supplementary oxygen should be administered
C. Unreliable; no supplementary oxygen is indicated
D. Unreliable; supplementary oxygen should be
administered - ANSWER-Unreliable; supplementary
oxygen should be administered
8. A mother brings her 7-year-old child to the emergency
department. The mother states that the child has had a
fever for the past 4 days and has had little to eat or drink
during the past 24 hours. Your initial impression reveals a
lethargic child with increased respiratory rate and pale
color. Heart rate is 160/min, respiratory rate is 38/min, and
blood pressure is 86/48 mm Hg. Capillary refill is 4
,seconds. Which of the following is the most appropriate
intervention for this child?
A. Fluid bolus of 10 mL/kg of isotonic crystalloid
B. Fluid bolus of 20 mL/kg of isotonic crystalloid
C. Maintenance fluid infusion of isotonic crystalloid at 10
mL/h
D. Maintenance fluid infusion of 5% dextrose and water at
20 mL/h - ANSWER-Fluid bolus of 20 mL/kg of isotonic
crystalloid
9. An intubated 5-year-old child who was in a motor
vehicle collision becomes increasingly more difficult to
ventilate. The child has diminished breath sounds and
chest expansion on the right side of the chest, with audible
, breath sounds and visible chest expansion on the left. The
endotracheal tube insertion depth has not changed. What
is the most appropriate intervention?
A. Deflate the cuff and pull the tube back
B. Perform needle decompression on the right chest
C. Perform needle decompression on the left chest D.
Insert a gastric tube - ANSWER-Perform needle
decompression on the right chest
10. A 2-year-old child with a 2-day history of a barking
cough presents with audible stridor on inspiration,
intercostal retractions, and agitation. What is the most
appropriate intervention for this child?
A. Lay the child flat on a stretcher
Exam With Complete Questions And Correct Detailed
Answers With Rationales (Verified Answers) |Already
Graded A+|Latest version
1. A 5-year-old child presents with lethargy, increased work
of breathing, and pale color. The primary assessment
reveals that the airway is open and the respiratory rate is
30/min, with crackles heard on auscultation. The cardiac
monitor shows sinus tachycardia at a rate of 165/min. The
pulse oximeter displays an oxygen saturation of 95% and
a pulse rate of 93/min. On the basis of this information,
which of the following provides the best interpretation of
the oxygen saturation of 95% by pulse oximetry?
,A. Reliable; no supplementary oxygen is indicated B.
Reliable; supplementary oxygen should be administered
C. Unreliable; no supplementary oxygen is indicated
D. Unreliable; supplementary oxygen should be
administered - ANSWER-Unreliable; supplementary
oxygen should be administered
8. A mother brings her 7-year-old child to the emergency
department. The mother states that the child has had a
fever for the past 4 days and has had little to eat or drink
during the past 24 hours. Your initial impression reveals a
lethargic child with increased respiratory rate and pale
color. Heart rate is 160/min, respiratory rate is 38/min, and
blood pressure is 86/48 mm Hg. Capillary refill is 4
,seconds. Which of the following is the most appropriate
intervention for this child?
A. Fluid bolus of 10 mL/kg of isotonic crystalloid
B. Fluid bolus of 20 mL/kg of isotonic crystalloid
C. Maintenance fluid infusion of isotonic crystalloid at 10
mL/h
D. Maintenance fluid infusion of 5% dextrose and water at
20 mL/h - ANSWER-Fluid bolus of 20 mL/kg of isotonic
crystalloid
9. An intubated 5-year-old child who was in a motor
vehicle collision becomes increasingly more difficult to
ventilate. The child has diminished breath sounds and
chest expansion on the right side of the chest, with audible
, breath sounds and visible chest expansion on the left. The
endotracheal tube insertion depth has not changed. What
is the most appropriate intervention?
A. Deflate the cuff and pull the tube back
B. Perform needle decompression on the right chest
C. Perform needle decompression on the left chest D.
Insert a gastric tube - ANSWER-Perform needle
decompression on the right chest
10. A 2-year-old child with a 2-day history of a barking
cough presents with audible stridor on inspiration,
intercostal retractions, and agitation. What is the most
appropriate intervention for this child?
A. Lay the child flat on a stretcher
