NGN ATI RN Pediatrics // Proctored
Exam Retake: Questions, Answers, &
Rationales
SECTION 1: PRIORITY SETTING & EMERGENCY NURSING
Q1. A nurse in the emergency department is assessing a toddler who
has hyperpyrexia, severe dyspnea, and is drooling. Which action
should the nurse take first?
A) Obtain a blood culture from the toddler
B) Administer an antibiotic to the toddler
C) Insert an IV catheter for the toddler
D) Prepare the toddler for nasotracheal intubation
Answer: D) Prepare the toddler for nasotracheal intubation
Rationale: Hyperpyrexia, severe dyspnea, and drooling are classic signs of
epiglottitis, a medical emergency that can cause complete airway
obstruction. The priority is preparing for intubation to secure the airway.
Throat examinations, blood cultures, and IV insertion should be deferred as
they may trigger laryngospasm or delay life-saving intervention .
,Q2. A nurse in an urgent care clinic is prioritizing care for four
children. Which child should the nurse assess first?
A) A toddler who has nephrotic syndrome and facial edema
B) A preschool-age child who has a muffled voice and no spontaneous
cough
C) A preschool-age child who has diabetes mellitus and a blood glucose of
200 mg/dL
D) An adolescent who has Crohn's disease and recent weight loss of 5 kg
Answer: B) A preschool-age child who has a muffled voice and no
spontaneous cough
Rationale: A muffled voice and no spontaneous cough in a preschooler
suggests epiglottitis or a severe airway obstruction. This is a life-threatening
emergency requiring immediate assessment. The other findings, while
requiring follow-up, are not immediately life-threatening .
Q3. A nurse is caring for a 2-year-old child who was found holding a
container of toilet bowl cleaner. The child's lips are edematous and
inflamed, and he is drooling. What is the priority action?
A) Remove the child's contaminated clothing
B) Check the child's respiratory status
C) Administer an antidote to the child
D) Establish IV access for the child
Answer: B) Check the child's respiratory status
Rationale: When applying the ABC (Airway, Breathing, Circulation)
framework, airway is always the highest priority. Edematous, inflamed lips
,and drooling indicate potential airway compromise from caustic ingestion.
NEVER induce vomiting for caustic ingestions as this causes further tissue
damage .
Q4. A nurse is caring for a school-age child who is receiving a blood
transfusion. Which manifestation should alert the nurse to a possible
hemolytic transfusion reaction?
A) Urticaria
B) Fever
C) Flank pain
D) Hypotension
Answer: C) Flank pain
Rationale: Flank pain is caused by the breakdown of RBCs and is an
indication of a hemolytic reaction to the blood transfusion. This is a medical
emergency requiring immediate stopping of the transfusion. Urticaria and
fever may indicate allergic or febrile reactions but are not specific to
hemolytic reactions .
Q5. A school nurse is assessing a 7-year-old student. Which finding
should the nurse identify as a potential indicator of physical abuse?
A) Bruising around the wrists
B) Front deciduous teeth missing
C) Abrasions on the knees
D) Weight in 45th percentile
, Answer: A) Bruising around the wrists
Rationale: Bruising around the wrists is suspicious for physical abuse, often
indicating the child was restrained or grabbed. Abrasions on the knees and
missing deciduous teeth are normal findings for this age. Weight in the
45th percentile is within expected range .
Q6. A child with suspected bacterial meningitis has which finding that
is MOST concerning?
A) Positive Brudzinski sign
B) Bulging anterior fontanel
C) Petechial rash on trunk and extremities
D) Fever of 102°F (38.9°C)
Answer: C) Petechial rash on trunk and extremities
Rationale: A petechial or purpuric rash suggests Neisseria
meningitidis (meningococcemia). This indicates rapid deterioration, septic
shock, and DIC, requiring emergent intervention. While the other findings
are expected with meningitis, the rash signals a higher urgency for
treatment .
Q7. A nurse is assessing a child who has been stung by a bee and is
allergic to insect stings. Which findings should the nurse expect if the
child develops anaphylaxis? (Select All That Apply)
Exam Retake: Questions, Answers, &
Rationales
SECTION 1: PRIORITY SETTING & EMERGENCY NURSING
Q1. A nurse in the emergency department is assessing a toddler who
has hyperpyrexia, severe dyspnea, and is drooling. Which action
should the nurse take first?
A) Obtain a blood culture from the toddler
B) Administer an antibiotic to the toddler
C) Insert an IV catheter for the toddler
D) Prepare the toddler for nasotracheal intubation
Answer: D) Prepare the toddler for nasotracheal intubation
Rationale: Hyperpyrexia, severe dyspnea, and drooling are classic signs of
epiglottitis, a medical emergency that can cause complete airway
obstruction. The priority is preparing for intubation to secure the airway.
Throat examinations, blood cultures, and IV insertion should be deferred as
they may trigger laryngospasm or delay life-saving intervention .
,Q2. A nurse in an urgent care clinic is prioritizing care for four
children. Which child should the nurse assess first?
A) A toddler who has nephrotic syndrome and facial edema
B) A preschool-age child who has a muffled voice and no spontaneous
cough
C) A preschool-age child who has diabetes mellitus and a blood glucose of
200 mg/dL
D) An adolescent who has Crohn's disease and recent weight loss of 5 kg
Answer: B) A preschool-age child who has a muffled voice and no
spontaneous cough
Rationale: A muffled voice and no spontaneous cough in a preschooler
suggests epiglottitis or a severe airway obstruction. This is a life-threatening
emergency requiring immediate assessment. The other findings, while
requiring follow-up, are not immediately life-threatening .
Q3. A nurse is caring for a 2-year-old child who was found holding a
container of toilet bowl cleaner. The child's lips are edematous and
inflamed, and he is drooling. What is the priority action?
A) Remove the child's contaminated clothing
B) Check the child's respiratory status
C) Administer an antidote to the child
D) Establish IV access for the child
Answer: B) Check the child's respiratory status
Rationale: When applying the ABC (Airway, Breathing, Circulation)
framework, airway is always the highest priority. Edematous, inflamed lips
,and drooling indicate potential airway compromise from caustic ingestion.
NEVER induce vomiting for caustic ingestions as this causes further tissue
damage .
Q4. A nurse is caring for a school-age child who is receiving a blood
transfusion. Which manifestation should alert the nurse to a possible
hemolytic transfusion reaction?
A) Urticaria
B) Fever
C) Flank pain
D) Hypotension
Answer: C) Flank pain
Rationale: Flank pain is caused by the breakdown of RBCs and is an
indication of a hemolytic reaction to the blood transfusion. This is a medical
emergency requiring immediate stopping of the transfusion. Urticaria and
fever may indicate allergic or febrile reactions but are not specific to
hemolytic reactions .
Q5. A school nurse is assessing a 7-year-old student. Which finding
should the nurse identify as a potential indicator of physical abuse?
A) Bruising around the wrists
B) Front deciduous teeth missing
C) Abrasions on the knees
D) Weight in 45th percentile
, Answer: A) Bruising around the wrists
Rationale: Bruising around the wrists is suspicious for physical abuse, often
indicating the child was restrained or grabbed. Abrasions on the knees and
missing deciduous teeth are normal findings for this age. Weight in the
45th percentile is within expected range .
Q6. A child with suspected bacterial meningitis has which finding that
is MOST concerning?
A) Positive Brudzinski sign
B) Bulging anterior fontanel
C) Petechial rash on trunk and extremities
D) Fever of 102°F (38.9°C)
Answer: C) Petechial rash on trunk and extremities
Rationale: A petechial or purpuric rash suggests Neisseria
meningitidis (meningococcemia). This indicates rapid deterioration, septic
shock, and DIC, requiring emergent intervention. While the other findings
are expected with meningitis, the rash signals a higher urgency for
treatment .
Q7. A nurse is assessing a child who has been stung by a bee and is
allergic to insect stings. Which findings should the nurse expect if the
child develops anaphylaxis? (Select All That Apply)
