Verified Questions with Answers & Rationales | Latest
Version for NCLEX Prep – Graded A+
A 4-year-old child presents with a high fever, cough, and difficulty breathing. The nurse notes wheezing
upon auscultation. What is the priority nursing intervention?
- correct answer B) Administer a bronchodilator
RATIONALE:: Administering a bronchodilator is the priority intervention to relieve wheezing and improve
the child's breathing.
A 10-year-old child with asthma is experiencing an exacerbation. The child is using a rescue inhaler every
2 hours. What should the nurse assess for next?
- correct answer C) Signs of respiratory failure
RATIONALE:: The nurse should assess for signs of respiratory failure, as frequent use of a rescue inhaler
indicates poor asthma control.
During a health assessment, a nurse observes that a 2-year-old child has a distended abdomen and is
irritable. The mother reports the child has not had a bowel movement in three days. What should the
nurse do first?
- correct answer C) Assess the child's abdomen further
RATIONALE:: Assessing the abdomen further is crucial to determine the extent of the issue before taking
action.
A nurse is teaching a group of parents about the importance of vaccinations for children. Which
statement indicates that a parent understands the teaching?
- correct answer C) "Vaccinations help prevent serious diseases."