2025 | 150 VERIFIED QUESTIONS WITH
ANSWERS & RATIONALES | LATEST
VERSION FOR NCLEX PREP – GRADED A+
B) Administer a bronchodilator
RATIONALE:: Administering a bronchodilator is the priority intervention to relieve wheezing and improve
the child's breathing. - answer ✔✔-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?
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. - answer ✔✔-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?
C) Assess the child's abdomen further
RATIONALE:: Assessing the abdomen further is crucial to determine the extent of the issue before taking
action. - answer ✔✔-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?
C) "Vaccinations help prevent serious diseases."