Published - Fri, 03 Mar 2023

NCLEX-RN Exam Questions - Part 37

1. The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?

A) 'Some say this feels like a pinch or a bug bite. You tell me what it feels like.'
B) 'This is going to hurt a lot; close your eyes and hold my hand.'
C) 'This is a terrible procedure, so don - t look.'
D) 'This will hurt only a little; try to be a big boy.'

2. The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

A) Place a tongue blade in the child - s mouth.
B) Restrain the child so he will not injure himself.
C) Go to the nurses station and call the physician.
D) Move furniture out of the way and place a blanket under his head.

3. A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?

A) Oral
B) IM
C) IV
D) Aerosol

4. A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

A) Fluid volume deficit
B) Fluid volume excess
C) Decreased cardiac output
D) Severe hypotension

5. Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body?

A) Urine output
B) Edema
C) Hypertension
D) Bulging fontanelle

1. Right Answer: A
Explanation: (A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D)False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.

2. Right Answer: D
Explanation: (A) The nurse should not put anything in the childs mouth during a seizure; this action could obstruct the airway. (B) Restraining the childs movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.

3. Right Answer: D
Explanation: (A) Ribavirin is not supplied in an oral form. (B) Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue.(C) Ribavirin is not approved for IV use to treat respiratory syncytial virus. (D) Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.

4. Right Answer: B
Explanation: (A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D)Hypertension is the result of hypervolemia.

5. Right Answer: A
Explanation: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. (B) Edema is an indication of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age.

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