NCLEX-PN Test #2 3 — Questions and Answers
Question 1: A 4-year-old child is admitted with suspected epiglottitis. Which nursing action is the highest priority?
- Obtain a throat culture immediately
- Keep the child calm and do not attempt to visualize the throat (Correct answer)
- Administer acetaminophen for fever
- Place the child in a supine position
Correct answer: Keep the child calm and do not attempt to visualize the throat
In epiglottitis, any stimulation (including throat examination) can cause complete airway obstruction. The priority is to keep the child calm and upright (sniffing position) and avoid throat visualization or throat culture until the airway is secured by an experienced provider.
Question 2: The PN is reviewing discharge teaching for a child with a new diagnosis of type 1 diabetes. Which statement by the parent indicates a need for further teaching?
- "I will check my child's blood sugar before meals and at bedtime."
- "If my child is sick and not eating, I should skip the insulin dose." (Correct answer)
- "I will rotate injection sites to prevent lipodystrophy."
- "Signs of low blood sugar include shakiness, sweating, and confusion."
Correct answer: "If my child is sick and not eating, I should skip the insulin dose."
Insulin must NOT be skipped during illness. Stress hormones released during illness raise blood glucose levels, often requiring the same or increased insulin doses. The rule is "sick day management" — check glucose more frequently and follow the provider's sick-day protocol.
Question 3: A client with major depressive disorder says, "I've decided to give away my most prized possessions." How should the PN respond?
- "That is very generous of you. Who will you give them to?"
- Notify the charge nurse immediately and implement suicide precautions (Correct answer)
- Document the statement and monitor the client closely
- "Are you feeling sad about parting with your belongings?"
Correct answer: Notify the charge nurse immediately and implement suicide precautions
Giving away prized possessions is a classic warning sign of suicidal intent (saying goodbye). This requires immediate action — notify the charge nurse and implement suicide precautions. Engaging in casual conversation or only documenting without action puts the client at serious risk.
Question 4: A 2-year-old is admitted with a febrile seizure. After the seizure, what is the priority nursing assessment?
- Assess pupillary response and level of consciousness (Correct answer)
- Obtain blood glucose level
- Check the child's temperature
- Measure head circumference
Correct answer: Assess pupillary response and level of consciousness
After any seizure, airway, breathing, and neurological status are the immediate priorities. Assessing the level of consciousness and pupillary response identifies postictal state and any neurological changes. Temperature is also important but neurological assessment takes priority in the immediate post-seizure period.
Question 5: A client with schizophrenia tells the PN, "The television is sending me secret messages about my mission." The nurse recognizes this as:
- Auditory hallucination
- Idea of reference (Correct answer)
- Neologism
- Echolalia
Correct answer: Idea of reference
An idea of reference is a type of delusion in which the client believes that external events (such as a TV broadcast) have special personal meaning directed at them. This is distinct from auditory hallucinations (hearing voices) and is a positive symptom of schizophrenia.
Question 6: The PN is caring for a child with sickle cell crisis. Which nursing intervention is the highest priority?
- Administer IV morphine for pain
- Provide supplemental oxygen
- Ensure IV fluid hydration (Correct answer)
- Position the child for comfort
Correct answer: Ensure IV fluid hydration
Hydration is the cornerstone of sickle cell crisis management. IV fluids reduce blood viscosity, prevent further sickling, and promote oxygen delivery to tissues. While all listed interventions are important, rehydration is the highest priority because it addresses the underlying pathophysiology.
NCLEX-PN Test #2 3
A 4-year-old child is admitted with suspected epiglottitis.
Which nursing action is the highest priority?