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PN 131 Comprehensive Final NCLEX
Questions and Answers 2024/2025
Which of the following is the most appropriate location for assessing the pulse of an infant
who is less than 1 year old?
1. Radial
2. Carotid
3. Brachial
4. Popliteal
3. Brachial
Rationale: To assess a pulse in an infant (i.e., a child <1 year old), the pulse is checked at the
brachial artery. The infant's relatively short, fat neck makes palpation of the carotid artery
difficult. The popliteal and radial pulses are also difficult to palpate in an infant.
A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis
of seizures. The nurse checks for causes of the seizure activity by:
1. Testing the child's urine for specific gravity
2. Asking the child what happens during a seizure
3. Obtaining a family history of psychiatric illness
4. Obtaining a history regarding factors that may occur before the seizure activity
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4. Obtaining a history regarding factors that may occur before the seizure activity
Rationale: Fever and infections increase the body's metabolic rate. This can cause seizure
activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance
can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would
increase intracranial pressure or cerebral edema. Some medications could cause seizures.
Specific gravity would not be a reliable test, because it varies, depending on the existing
condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not
remember what happened during the seizure itself.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is
most appropriate for this child?
1. Encouraging the infant to hold a bottle
2. Keeping the infant on bed rest to conserve energy
3. Rotating caregivers to provide more stimulation
4. Maintaining a consistent, structured environment
4. Maintaining a consistent, structured environment
RATIONALE: The nurse caring for an infant with inorganic failure to thrive should strive to
maintain a consistent, structured environment because it reinforces a caring feeding
environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding
environment. The infant should receive social stimulation rather than be confined to bed rest.
The number of caregivers should be minimized to promote consistency of care.
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A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg
P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse
administer with each dose?
1. 50 mg
2. 100 mg
3. 110 mg
4. 220 mg
1. 50 mg
RATIONALE: The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the
nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To
improve oxygenation during such an episode, the nurse should place the infant in which
position?
1. Knee-to-chest
2. Fowler's
3. Trendelenburg's
4. Prone
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1. Knee-to-chest
RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy,
ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD.
Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD,
causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest
position because this position reduces venous return from the legs and increases systemic
vascular resistance, maximizing pulmonary blood flow and improving oxygenation status.
Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
A mother is discontinuing breast-feeding after 5 months. What should the nurse advise the
mother to include in her infant's diet?
1. Iron-rich formula and baby food
2. Whole milk and baby food
3. Skim milk and baby food
4. Iron-rich formula alone
4. Iron-rich formula alone
RATIONALE: The American Academy of Pediatrics recommends iron-rich formula for 5-month-
old infants and cautions against giving infants solid food — even baby food — until age 6
months. The Academy doesn't recommend whole milk before age 12 months or skim milk
before age 2 years.
1|Page| GradeA+ | 2 0 0 2 5
PN 131 Comprehensive Final NCLEX
Questions and Answers 2024/2025
Which of the following is the most appropriate location for assessing the pulse of an infant
who is less than 1 year old?
1. Radial
2. Carotid
3. Brachial
4. Popliteal
3. Brachial
Rationale: To assess a pulse in an infant (i.e., a child <1 year old), the pulse is checked at the
brachial artery. The infant's relatively short, fat neck makes palpation of the carotid artery
difficult. The popliteal and radial pulses are also difficult to palpate in an infant.
A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis
of seizures. The nurse checks for causes of the seizure activity by:
1. Testing the child's urine for specific gravity
2. Asking the child what happens during a seizure
3. Obtaining a family history of psychiatric illness
4. Obtaining a history regarding factors that may occur before the seizure activity
1|Page| GradeA+ | 2 0 0 2 5
,2 0 2 4 /2025 | © copyright | This work may not be copied for profit gain Excel!
4. Obtaining a history regarding factors that may occur before the seizure activity
Rationale: Fever and infections increase the body's metabolic rate. This can cause seizure
activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance
can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would
increase intracranial pressure or cerebral edema. Some medications could cause seizures.
Specific gravity would not be a reliable test, because it varies, depending on the existing
condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not
remember what happened during the seizure itself.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is
most appropriate for this child?
1. Encouraging the infant to hold a bottle
2. Keeping the infant on bed rest to conserve energy
3. Rotating caregivers to provide more stimulation
4. Maintaining a consistent, structured environment
4. Maintaining a consistent, structured environment
RATIONALE: The nurse caring for an infant with inorganic failure to thrive should strive to
maintain a consistent, structured environment because it reinforces a caring feeding
environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding
environment. The infant should receive social stimulation rather than be confined to bed rest.
The number of caregivers should be minimized to promote consistency of care.
1|Page| GradeA+ | 2 0 0 2 5
,2 0 2 4 /2025 | © copyright | This work may not be copied for profit gain Excel!
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg
P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse
administer with each dose?
1. 50 mg
2. 100 mg
3. 110 mg
4. 220 mg
1. 50 mg
RATIONALE: The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the
nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To
improve oxygenation during such an episode, the nurse should place the infant in which
position?
1. Knee-to-chest
2. Fowler's
3. Trendelenburg's
4. Prone
1|Page| GradeA+ | 2 0 0 2 5
, 2 0 2 4 /2025 | © copyright | This work may not be copied for profit gain Excel!
1. Knee-to-chest
RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy,
ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD.
Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD,
causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest
position because this position reduces venous return from the legs and increases systemic
vascular resistance, maximizing pulmonary blood flow and improving oxygenation status.
Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
A mother is discontinuing breast-feeding after 5 months. What should the nurse advise the
mother to include in her infant's diet?
1. Iron-rich formula and baby food
2. Whole milk and baby food
3. Skim milk and baby food
4. Iron-rich formula alone
4. Iron-rich formula alone
RATIONALE: The American Academy of Pediatrics recommends iron-rich formula for 5-month-
old infants and cautions against giving infants solid food — even baby food — until age 6
months. The Academy doesn't recommend whole milk before age 12 months or skim milk
before age 2 years.
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