NCLEX-Style Practice Questions Based on ATI RN

NCLEX-Style Practice Questions Based on ATI RN Pediatric Nursing Edition 12.0 Chapter 2 Leave the first rating Students also studied Terms in this set (10) Science MedicinePaediatrics Save NCLEX-Style Practice Questions Bas...18 terms Google_Us_1234 Preview Pediatric NCLEX Questions 66 terms farzana_talPreview Peds Exam 1 NCLEX style questions 37 terms alanna_buonanno Preview Peds Ex 149 term Abi A nurse is preparing to assess a 5-year-old child during a well-child visit. Which of the following actions should the nurse take? (Select all that apply.)

• Explain each step of the examination to the child.
• Use medical terminology to describe what will happen.
• Allow the child to role-play using miniature equipment.
• Separate the child from the caregiver during the

examination.

• Allow the child to manipulate and handle equipment.

A, C, E

Rationale: Children should be allowed to role-play using miniature equipment,

and the nurse should explain the steps of the examination using age-appropriate language. Allowing the child to handle equipment can also reduce anxiety.A nurse is performing a physical assessment on a 2-year- old toddler. Which of the following actions should the nurse take? (Select all that apply.)

• Begin the assessment with the most invasive

procedures first.

• Allow the toddler to sit on the caregiver's lap during

the examination.

• Use a calm voice and be firm about expected behavior.
• Keep medical equipment visible to the toddler.
• Take time to play and develop rapport prior to

beginning the examination.

B, C, E

Rationale: Allowing the toddler to sit on the caregiver's lap, using a calm voice, and playing to develop rapport can help make the examination less threatening.A nurse is checking the vital signs of a 4-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider?

• Temperature 37.5°C (99.5°F)
• Heart rate 120/min
• Respirations 28/min
• Blood pressure 100/60 mm Hg

C Rationale: A respiratory rate of 28/min is higher than the expected range for a 4- year-old and should be reported.

A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse expect? (Select all that apply.)

• Temperature of 37.5°C (99.5°F) taken rectally
• Heart rate of 140/min
• Respirations of 20/min
• Anterior fontanel that is bulging
• Erect head posture

A, B Rationale: A temperature of 37.5°C (99.5°F) and a heart rate of 140/min are within the expected range for a 3-month-old infant.A nurse is assessing the respiratory status of a 7-year-old child. Which of the following findings should the nurse expect?

• Respiratory rate of 35/min
• Symmetric chest movement
• Vesicular breath sounds heard over most of the lungs
• Presence of retractions

B, C

Rationale: Symmetric chest movement and vesicular breath sounds are expected

findings in a 7-year-old child.A nurse is assessing the growth and development of a 12- month-old infant. Which of the following findings should prompt the nurse to refer the infant for further evaluation?

• The infant has six teeth.
• The infant can stand without support.
• The infant is not yet walking.
• The infant's head circumference has not increased in

the past month.D Rationale: Lack of head circumference increase may indicate an issue with growth and development, prompting further evaluation.A nurse is performing a physical assessment on a 4-year- old boy. Which of the following findings should the nurse expect? (Select all that apply.)

• Foreskin that is retractable
• Scrotum that hangs separately from the penis
• Urethral meatus located at the tip of the penis
• Presence of pubic hair
• Symmetric labia majora and minora

B, C

Rationale: The scrotum should hang separately from the penis, and the urethral

meatus should be at the tip of the penis in a 4-year-old boy.A nurse is assessing the ears of a 2-year-old child. Which of the following findings should the nurse expect?

• Tympanic membrane that is pearly gray in color
• Light reflex at the 2 o'clock position
• Bony landmarks not visible
• Cerumen is absent bilaterally

A

Rationale: The tympanic membrane should be pearly gray in color, which is an

expected finding in a 2-year-old child.A nurse is assessing the eyes of a 5-year-old child. Which of the following findings should the nurse expect? (Select all that apply.)

• Visual acuity of 20/50 in both eyes
• Pupils that are equal in size and reactive to light
• Symmetric corneal light reflex
• Presence of nystagmus during the six cardinal fields of

gaze test

• Pink conjunctiva and clear sclera

B, C, E

Rationale: Pupils that are equal in size and reactive to light, symmetric corneal light reflex, and pink conjunctiva with clear sclera are normal findings.

A nurse is measuring the blood pressure of a 6-year-old child. Which of the following blood pressure readings should the nurse report to the provider as being outside the normal range?

• 98/60 mm Hg
• 110/75 mm Hg
• 116/80 mm Hg
• 100/65 mm Hg

C Rationale: A blood pressure of 116/80 mm Hg is outside the normal range for a 6- year-old child and should be reported.