NUR 114
EXAM 4
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child with burns during treatment. Which
assessment provides the most accurate guide to determine the
adequacy of fluid resuscitation?
1. Skin turgor
2. Level of edema at burn site
3. Adequacy of capillary filling
4. Amount of fluid tolerated in 24 hours
Answer: 3
Rationale: Parameters such as vital signs (especially heart rate), urinary
output volume, adequacy of capillary filling, and state of sensorium
determine adequacy of fluid resuscitation. Although options 1, 2, and 4
may provide some information related to fluid volume, in a burn injury,
and from the options provided, adequacy of capillary filling is most
accurate.
Test-Taking Strategy: Note the strategic word, most. Use the ABCs—
airway, breathing, and circulation—to assist in directing you to the
correct option.
The nurse caring for a child who sustained a burn injury plans care
based on which pediatric considerations associated with this injury?
Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of
,infection for infants and young children.
4. Fluid resuscitation is unnecessary unless the burned area is more
than 25% of the total body surface area.
5. The lower proportion of body fluid to body mass in a child
increases the risk of cardiovascular problems.
6. Infants and young children are at increased risk for protein and
calorie deficiency, because they have smaller muscle mass and less
body fat than adults.
Answer: 2, 3, 6
Rationale: Pediatric considerations in the care of a burn victim include
the following: Scarring is more severe in a child than in an adult. A
delay in growth may occur after a burn injury. An immature immune
system presents an increased risk of infection for infants and young
children. The higher proportion of body fluid to body mass in a child
increases the risk of cardiovascular problems. Burns involving more
than 10% of total body surface area require some form of fluid
resuscitation. Infants and young children are at increased risk for
protein and calorie deficiencies because they have smaller muscle mass
and less body fat than adults.
Test-Taking Strategy: Focus on the subject, pediatric considerations in
the care of a child who has sustained a burn injury. To answer correctly,
read each option carefully and think about the physiology of a child
related to body size.
, The nurse provides home care instructions to the parents of a child
with heart failure regarding the procedure for administration of
digoxin. Which statement made by the parent indicates the need for
further instruction?
1. "I will not mix the medication with food."
2. "If more than one dose is missed, I will call the pediatrician."
3. "I will take my child's pulse before administering the medication."
4. "If my child vomits after medication administration, I will repeat
the dose."
Answer: 4
Rationale: Digoxin is a cardiac glycoside. The parents need to be
instructed that if the child vomits after digoxin is administered, they are
not to repeat the dose. Options 1, 2, and 3 are accurate instructions
regarding the administration of this medication. In addition, the
parents need to be instructed that if a dose is missed and the missed
dose is not identified until 4 hours later, the dose would not be
administered.
Test-Taking Strategy: Note the strategic words, need for further
instruction. These words indicate a negative event query and ask you to
select an option that is an incorrect statement. General knowledge
regarding digoxin administration will assist in eliminating option 2.
Principles related to administering medications to children will assist in
eliminating option 1. From the remaining options, select the correct
EXAM 4
NCLEX Style Questions w/
Rationales & Test Taking Strategies
Jefferson State Community College
This Document Description:
❖ This document contains NCLEX-style Exam
questions tailored to the NUR 114 course at
Jefferson State Community College.
❖ It covers core topics assessed in the course
and reflects the actual exam format and question style.
❖ Each question is followed by a correct answer, rationale, and
test-taking strategy to support exam preparation.
,The nurse is monitoring a child with burns during treatment. Which
assessment provides the most accurate guide to determine the
adequacy of fluid resuscitation?
1. Skin turgor
2. Level of edema at burn site
3. Adequacy of capillary filling
4. Amount of fluid tolerated in 24 hours
Answer: 3
Rationale: Parameters such as vital signs (especially heart rate), urinary
output volume, adequacy of capillary filling, and state of sensorium
determine adequacy of fluid resuscitation. Although options 1, 2, and 4
may provide some information related to fluid volume, in a burn injury,
and from the options provided, adequacy of capillary filling is most
accurate.
Test-Taking Strategy: Note the strategic word, most. Use the ABCs—
airway, breathing, and circulation—to assist in directing you to the
correct option.
The nurse caring for a child who sustained a burn injury plans care
based on which pediatric considerations associated with this injury?
Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of
,infection for infants and young children.
4. Fluid resuscitation is unnecessary unless the burned area is more
than 25% of the total body surface area.
5. The lower proportion of body fluid to body mass in a child
increases the risk of cardiovascular problems.
6. Infants and young children are at increased risk for protein and
calorie deficiency, because they have smaller muscle mass and less
body fat than adults.
Answer: 2, 3, 6
Rationale: Pediatric considerations in the care of a burn victim include
the following: Scarring is more severe in a child than in an adult. A
delay in growth may occur after a burn injury. An immature immune
system presents an increased risk of infection for infants and young
children. The higher proportion of body fluid to body mass in a child
increases the risk of cardiovascular problems. Burns involving more
than 10% of total body surface area require some form of fluid
resuscitation. Infants and young children are at increased risk for
protein and calorie deficiencies because they have smaller muscle mass
and less body fat than adults.
Test-Taking Strategy: Focus on the subject, pediatric considerations in
the care of a child who has sustained a burn injury. To answer correctly,
read each option carefully and think about the physiology of a child
related to body size.
, The nurse provides home care instructions to the parents of a child
with heart failure regarding the procedure for administration of
digoxin. Which statement made by the parent indicates the need for
further instruction?
1. "I will not mix the medication with food."
2. "If more than one dose is missed, I will call the pediatrician."
3. "I will take my child's pulse before administering the medication."
4. "If my child vomits after medication administration, I will repeat
the dose."
Answer: 4
Rationale: Digoxin is a cardiac glycoside. The parents need to be
instructed that if the child vomits after digoxin is administered, they are
not to repeat the dose. Options 1, 2, and 3 are accurate instructions
regarding the administration of this medication. In addition, the
parents need to be instructed that if a dose is missed and the missed
dose is not identified until 4 hours later, the dose would not be
administered.
Test-Taking Strategy: Note the strategic words, need for further
instruction. These words indicate a negative event query and ask you to
select an option that is an incorrect statement. General knowledge
regarding digoxin administration will assist in eliminating option 2.
Principles related to administering medications to children will assist in
eliminating option 1. From the remaining options, select the correct
