NCLEX-RN Review: – 18-Month-Old
with Acute Cough (Viral URI)
Practice Exam – Real Questions and
Verified Answers for Guaranteed
Success
Case Reference for All Questions
*Michael Martinez is an 18-month-old male who presents with a 4-day
history of cough and rhinorrhea. Vital signs: T 99.8°F (axillary), HR
118, RR 32, SpO₂ 98% on room air. Exam: clear rhinorrhea, mild
pharyngeal erythema, clear lung sounds with intermittent coarse breath
sounds that clear with cough. No wheezing, retractions, or stridor.
History: daycare attendance, sibling with URI one week ago, mother has
asthma, patient had infantile eczema (resolved). Immunizations UTD
except influenza.*
Questions 1-10: Assessment & Priority
,Question 1
The nurse assesses an 18-month-old child with a cough. Which
finding requires immediate intervention?
A. Respiratory rate of 32 breaths per minute
B. Temperature of 99.8°F axillary
C. Nasal flaring and supraclavicular retractions
D. Intermittent dry cough during play
,,,,answer,,,,: C
Rationale: Nasal flaring and retractions are signs of increased work of
breathing and respiratory distress requiring immediate intervention. The
other findings are normal or expected for viral URI.
Question 2
The nurse is prioritizing assessment findings for an 18-month-old
with a cough. Which finding should the nurse report to the provider
FIRST?
A. Decreased appetite for 2 days
B. Awakening once at night with cough
C. Oxygen saturation of 91% on room air
D. Five wet diapers in the past 24 hours
,,,,answer,,,,: C
*Rationale: SpO₂ of 91% is below the normal range (≥95% for a healthy
child) and indicates hypoxemia. This is an airway/breathing priority.
Decreased appetite and nighttime cough are expected with URI. Five
wet diapers indicates adequate hydration.*
,Question 3
The mother reports that Michael "sounds like a seal" when he
coughs. What is the nurse's priority action?
A. Administer a bronchodilator
B. Assess for stridor and respiratory distress
C. Give a dose of oral dexamethasone
D. Reassure the mother this is normal for a cold
,,,,answer,,,,: B
Rationale: A "seal-like" barking cough suggests croup. The priority is to
assess airway, breathing, and oxygenation (stridor, retractions, SpO₂)
before any intervention. Dexamethasone may be indicated after
assessment, but assessment comes first.
Question 4
The nurse notes that Michael has developed inspiratory stridor at
rest. What is the priority nursing action?
A. Place the child in a supine position
B. Administer a nebulized epinephrine treatment
C. Notify the provider and prepare for possible transfer
D. Offer the child a cold liquid to drink
,,,,answer,,,,: C
Rationale: Inspiratory stridor at rest indicates moderate to severe
, airway obstruction. The provider must be notified immediately.
Nebulized epinephrine may be ordered, but notification and preparation
for possible escalation of care (transfer, steroids, airway support) is
priority.
Question 5
Which assessment finding in an 18-month-old with cough is the
BEST indicator of adequate hydration?
A. Moist oral mucosa
B. Tears when crying
C. Six wet diapers in 24 hours
D. Drinking 4 ounces of water per hour
,,,,answer,,,,: C
Rationale: Number of wet diapers is the most objective and reliable
indicator of hydration status in infants and toddlers. Six wet diapers in
24 hours is normal. Moist mucous membranes and tears are also signs
but can be subjective.
Question 6
The nurse is assessing Michael's respiratory status. Which finding is
NORMAL for an 18-month-old?
A. Respiratory rate of 42 breaths per minute
B. Expiratory wheezing heard on auscultation
with Acute Cough (Viral URI)
Practice Exam – Real Questions and
Verified Answers for Guaranteed
Success
Case Reference for All Questions
*Michael Martinez is an 18-month-old male who presents with a 4-day
history of cough and rhinorrhea. Vital signs: T 99.8°F (axillary), HR
118, RR 32, SpO₂ 98% on room air. Exam: clear rhinorrhea, mild
pharyngeal erythema, clear lung sounds with intermittent coarse breath
sounds that clear with cough. No wheezing, retractions, or stridor.
History: daycare attendance, sibling with URI one week ago, mother has
asthma, patient had infantile eczema (resolved). Immunizations UTD
except influenza.*
Questions 1-10: Assessment & Priority
,Question 1
The nurse assesses an 18-month-old child with a cough. Which
finding requires immediate intervention?
A. Respiratory rate of 32 breaths per minute
B. Temperature of 99.8°F axillary
C. Nasal flaring and supraclavicular retractions
D. Intermittent dry cough during play
,,,,answer,,,,: C
Rationale: Nasal flaring and retractions are signs of increased work of
breathing and respiratory distress requiring immediate intervention. The
other findings are normal or expected for viral URI.
Question 2
The nurse is prioritizing assessment findings for an 18-month-old
with a cough. Which finding should the nurse report to the provider
FIRST?
A. Decreased appetite for 2 days
B. Awakening once at night with cough
C. Oxygen saturation of 91% on room air
D. Five wet diapers in the past 24 hours
,,,,answer,,,,: C
*Rationale: SpO₂ of 91% is below the normal range (≥95% for a healthy
child) and indicates hypoxemia. This is an airway/breathing priority.
Decreased appetite and nighttime cough are expected with URI. Five
wet diapers indicates adequate hydration.*
,Question 3
The mother reports that Michael "sounds like a seal" when he
coughs. What is the nurse's priority action?
A. Administer a bronchodilator
B. Assess for stridor and respiratory distress
C. Give a dose of oral dexamethasone
D. Reassure the mother this is normal for a cold
,,,,answer,,,,: B
Rationale: A "seal-like" barking cough suggests croup. The priority is to
assess airway, breathing, and oxygenation (stridor, retractions, SpO₂)
before any intervention. Dexamethasone may be indicated after
assessment, but assessment comes first.
Question 4
The nurse notes that Michael has developed inspiratory stridor at
rest. What is the priority nursing action?
A. Place the child in a supine position
B. Administer a nebulized epinephrine treatment
C. Notify the provider and prepare for possible transfer
D. Offer the child a cold liquid to drink
,,,,answer,,,,: C
Rationale: Inspiratory stridor at rest indicates moderate to severe
, airway obstruction. The provider must be notified immediately.
Nebulized epinephrine may be ordered, but notification and preparation
for possible escalation of care (transfer, steroids, airway support) is
priority.
Question 5
Which assessment finding in an 18-month-old with cough is the
BEST indicator of adequate hydration?
A. Moist oral mucosa
B. Tears when crying
C. Six wet diapers in 24 hours
D. Drinking 4 ounces of water per hour
,,,,answer,,,,: C
Rationale: Number of wet diapers is the most objective and reliable
indicator of hydration status in infants and toddlers. Six wet diapers in
24 hours is normal. Moist mucous membranes and tears are also signs
but can be subjective.
Question 6
The nurse is assessing Michael's respiratory status. Which finding is
NORMAL for an 18-month-old?
A. Respiratory rate of 42 breaths per minute
B. Expiratory wheezing heard on auscultation
