Pediatric NCLEX Complex Questions And
Answers With Rationales
1.A 2-year-old with epiglottitis arrives in the ED. Which action should the
nurse perform first?
A. Obtain a throat culture
B. Place the child in supine position
C.Prepare for emergency airway management
D. Insert an oral airway
Answer:C
Rationale: Epiglottitis can cause sudden airway obstruction. Maintaining a patent airway is the
priority. Throat examination may trigger complete obstruction.
2. A child with Tetralogy of Fallot suddenly becomes cyanotic and dyspneic.What
is the priority intervention?
A.Administer digoxin
B.Place the child in knee-chest position
C. Restrict fluids
D. Place in Trendelenburg position
Answer: B
Rationale: The knee-chest position increases systemic vascular resistance and decreases
right-to-left shunting during a hypercyanotic ("tet") spell.
3. Which assessment finding in a newborn requires immediate intervention?
A.Acrocyanosis of hands and feet
B.Respiratory rate of 64/min with grunting
C. Heart rate of 140/min
D.Vernix on skin
Answer: B
, Rationale: Grunting indicates respiratory distress and possible neonatal respiratory failure.
4. A child with bacterial meningitis is receiving IV antibiotics. Which finding
should the nurse report immediately?
A. Temperature 38.2℃ (100.8°℉)
B. Positive Kernig sign
C.Decreased level of consciousness
D.Neck stiffness
Answer:C
Rationale:Decreased LOC may indicate increased intracranial pressure (ICP), a life-threatening
complication.
5. A 6-year-old with nephrotic syndrome has generalized edema.Which
nursing intervention is most important?
A. Encourage unrestricted activity
B.Weigh daily at the same time
C.Increase sodium intake
D. Restrict protein
Answer: B
Rationale: Daily weight is the most accurate indicator of fluid status.
6. A child with acute glomerulonephritis develops a BP of 150/98 mmHg.What
complication is the nurse most concerned about?
A.Hypoglycemia
B.Seizures
C.Dehydration
D.Hypothermia
Answer: B
Rationale:Severe hypertension can cause hypertensive encephalopathy and seizures.
7. A child with DKA is admitted. Which provider order should the nurse
Answers With Rationales
1.A 2-year-old with epiglottitis arrives in the ED. Which action should the
nurse perform first?
A. Obtain a throat culture
B. Place the child in supine position
C.Prepare for emergency airway management
D. Insert an oral airway
Answer:C
Rationale: Epiglottitis can cause sudden airway obstruction. Maintaining a patent airway is the
priority. Throat examination may trigger complete obstruction.
2. A child with Tetralogy of Fallot suddenly becomes cyanotic and dyspneic.What
is the priority intervention?
A.Administer digoxin
B.Place the child in knee-chest position
C. Restrict fluids
D. Place in Trendelenburg position
Answer: B
Rationale: The knee-chest position increases systemic vascular resistance and decreases
right-to-left shunting during a hypercyanotic ("tet") spell.
3. Which assessment finding in a newborn requires immediate intervention?
A.Acrocyanosis of hands and feet
B.Respiratory rate of 64/min with grunting
C. Heart rate of 140/min
D.Vernix on skin
Answer: B
, Rationale: Grunting indicates respiratory distress and possible neonatal respiratory failure.
4. A child with bacterial meningitis is receiving IV antibiotics. Which finding
should the nurse report immediately?
A. Temperature 38.2℃ (100.8°℉)
B. Positive Kernig sign
C.Decreased level of consciousness
D.Neck stiffness
Answer:C
Rationale:Decreased LOC may indicate increased intracranial pressure (ICP), a life-threatening
complication.
5. A 6-year-old with nephrotic syndrome has generalized edema.Which
nursing intervention is most important?
A. Encourage unrestricted activity
B.Weigh daily at the same time
C.Increase sodium intake
D. Restrict protein
Answer: B
Rationale: Daily weight is the most accurate indicator of fluid status.
6. A child with acute glomerulonephritis develops a BP of 150/98 mmHg.What
complication is the nurse most concerned about?
A.Hypoglycemia
B.Seizures
C.Dehydration
D.Hypothermia
Answer: B
Rationale:Severe hypertension can cause hypertensive encephalopathy and seizures.
7. A child with DKA is admitted. Which provider order should the nurse
