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These practice questions target NCLEX-RN level clinical judgment in pediatric nursing: recognition of pediatric emergencies, prioritization among unstable children, complication management, and weight-based dose calculation and verification. Work each calculation before viewing the answer.

==Question 1==
A 3-year-old is brought to the emergency department with a temperature of 39.4 degrees Celsius, drooling, a muffled voice, and no cough. The child is sitting upright, leaning forward with the chin thrust out, and appears anxious. Which action should the nurse take '''first'''?
# Obtain a throat culture to identify the causative organism.
# Place the child in a supine position and start an intravenous line.
# Keep the child upright in the parent's lap and notify the provider immediately while emergency airway equipment is brought to the bedside.
# Depress the tongue with a blade to visualize the posterior pharynx.

'''Answer:''' 3. Keep the child upright in the parent's lap and notify the provider immediately while emergency airway equipment is brought to the bedside.

''Rationale:'' The four Ds (drooling, dysphagia, dysphonia, distress), tripod positioning, absent cough, and high fever describe epiglottitis, an airway emergency. Keeping the child calm and upright preserves the airway, and skilled airway personnel and equipment must be assembled before anything else. Options 1 and 4 are contraindicated because manipulating the oropharynx can trigger laryngospasm and complete obstruction. Option 2 is wrong on both counts: supine positioning worsens obstruction, and the distress of an intravenous stick may precipitate airway collapse before airway support is available.

==Question 2==
The nurse assesses a 4-year-old with a 2-day history of vomiting and diarrhea. Which findings indicate '''compensated shock''' and require immediate intervention? '''Select all that apply.'''
# Heart rate 168 beats per minute
# Capillary refill of 4 seconds
# Blood pressure 92/58 mmHg
# Cool, mottled extremities with weak peripheral pulses but strong central pulses
# Increasing lethargy and decreased response to the parent's voice
# Urine output of 0.3 mL/kg/hr

'''Answer:''' 1, 2, 4, 5, and 6.

''Rationale:'' Children compensate for volume loss with tachycardia and peripheral vasoconstriction. Tachycardia, delayed capillary refill beyond 2 to 3 seconds, cool mottled skin with a central-to-peripheral pulse discrepancy, declining level of consciousness, and oliguria (expected output for a child is 1 to 2 mL/kg/hr) all indicate compensated shock. Option 3 is not a sign of shock: the hypotension threshold for a 4-year-old is a systolic pressure below 70 + (2 x 4), or 78 mmHg, so 92 mmHg is within normal limits. That is exactly the trap. Hypotension is a late and ominous sign, and the nurse must intervene on the compensated findings rather than waiting for the blood pressure to fall.

==Question 3==
A child weighing 33 lb is prescribed ceftriaxone 50 mg/kg intravenously once daily. The reconstituted vial contains 100 mg/mL. How many milliliters should the nurse administer? Record your answer to the nearest tenth.
# 3.3 mL
# 7.5 mL
# 15.0 mL
# 16.5 mL

'''Answer:''' 2. 7.5 mL

''Rationale:'' Convert the weight: 33 lb divided by 2.2 equals 15 kg. Multiply: 15 kg x 50 mg/kg equals 750 mg. Divide by the concentration: 750 mg divided by 100 mg/mL equals 7.5 mL. Option 1 results from dividing the pounds by 10; option 3 comes from using the weight in kilograms as the volume; option 4 comes from failing to convert pounds to kilograms.

==Question 4==
The nurse on a pediatric unit receives report on four children. Which child should the nurse assess '''first'''?
# A 6-month-old with bronchiolitis whose respiratory rate has decreased from 66 to 28 breaths per minute and who is now difficult to arouse
# A 4-year-old with asthma who is wheezing audibly and using accessory muscles after a nebulizer treatment
# A 10-year-old in sickle cell vaso-occlusive crisis who rates leg pain 8 out of 10 and is due for morphine
# A 2-year-old with gastroenteritis who has had one episode of emesis in the last hour and dry mucous membranes

'''Answer:''' 1. The 6-month-old with bronchiolitis whose respiratory rate has fallen and who is difficult to arouse.

''Rationale:'' A falling respiratory rate combined with decreasing responsiveness in a previously tachypneic infant signals exhaustion and impending respiratory failure and arrest, not improvement. This is the classic pediatric deterioration pattern and takes priority. The child in option 2 is in distress but is still moving air and ventilating audibly, which is less ominous than a quiet, obtunded infant. Options 3 and 4 are urgent but stable problems that follow.

==Question 5==
A child weighing 8 kg has an order for furosemide 20 mg intravenously every 12 hours. The reference safe range is 1 to 2 mg/kg per dose. What is the nurse's '''best''' action?
# Administer the dose as prescribed, since furosemide has a wide safety margin.
# Administer 16 mg and document the adjustment as a nursing intervention.
# Hold the dose and contact the prescriber to clarify the order.
# Give half the dose now and the remaining half in 6 hours.

'''Answer:''' 3. Hold the dose and contact the prescriber to clarify the order.

''Rationale:'' The safe range is 8 to 16 mg per dose (8 kg x 1 to 2 mg/kg). The ordered 20 mg exceeds the maximum safe dose, so the nurse must hold the medication and clarify with the prescriber. Option 1 administers a known overdose. Options 2 and 4 involve the nurse altering a prescribed dose or schedule, which is outside the scope of registered nursing practice and constitutes prescribing.

==Question 6==
A 2-year-old is diagnosed with Kawasaki disease and has received intravenous immunoglobulin. Which statements should the nurse include in discharge teaching? '''Select all that apply.'''
# "Your child will need follow-up echocardiograms to check the coronary arteries."
# "The measles-mumps-rubella and varicella vaccines should be delayed for about 11 months."
# "Peeling skin on the fingers and toes is expected and is not a sign of infection."
# "Stop the aspirin as soon as the fever resolves."
# "Call us if your child develops fever again after going home."
# "Extreme irritability during the illness is common and will gradually resolve."

'''Answer:''' 1, 2, 3, 5, and 6.

''Rationale:'' The feared complication of Kawasaki disease is coronary artery aneurysm, so serial echocardiography is standard. High-dose IVIG contains passive antibody that blunts the response to live vaccines, so MMR and varicella are deferred approximately 11 months. Periungual desquamation occurs in the subacute phase and is expected. Recurrent fever may signal IVIG resistance or ongoing inflammation and must be reported. Marked irritability is characteristic. Option 4 is incorrect: aspirin is continued, at an antiplatelet dose, after the anti-inflammatory phase, and is stopped only on the cardiologist's direction based on coronary findings. Kawasaki disease is one of the few pediatric indications for aspirin.

==Question 7==
A 4-week-old infant is admitted with a 5-day history of forceful vomiting after feedings. Which findings support a diagnosis of hypertrophic pyloric stenosis? '''Select all that apply.'''
# Bile-stained emesis
# Projectile vomiting followed by immediate hunger
# A firm, movable, olive-shaped mass in the right upper quadrant
# Serum chloride 88 mEq/L and serum bicarbonate 32 mEq/L
# Currant jelly stools
# Visible peristaltic waves moving across the upper abdomen

'''Answer:''' 2, 3, 4, and 6.

''Rationale:'' Pyloric stenosis obstructs at the gastric outlet, producing non-bilious projectile vomiting in an infant who remains hungry, a palpable olive-shaped pylorus, and visible left-to-right peristaltic waves. Persistent loss of gastric hydrochloric acid produces a hypochloremic, hypokalemic metabolic alkalosis, consistent with the low chloride and elevated bicarbonate in option 4. Option 1 is wrong because the obstruction is proximal to the ampulla of Vater, so emesis is non-bilious; bilious emesis suggests a distal obstruction such as malrotation with volvulus and is an emergency. Option 5 describes intussusception.

==Question 8==
An 11-month-old is being observed for suspected intussusception. The parent reports that the infant has just passed a normal, formed brown stool. What is the nurse's '''priority''' action?
# Document the finding as a routine bowel movement.
# Notify the provider immediately, because the planned reduction procedure may no longer be indicated.
# Offer clear liquids, since the obstruction has clearly resolved.
# Reassure the parent that this finding is unrelated to the diagnosis.

'''Answer:''' 2. Notify the provider immediately, because the planned reduction procedure may no longer be indicated.

''Rationale:'' Passage of a normal brown stool in a child with intussusception may indicate spontaneous reduction of the telescoped bowel. This changes the plan of care and must be reported before an enema reduction or surgery proceeds. Option 1 under-reacts to a plan-changing finding. Option 3 is unsafe because the child remains NPO until reduction is confirmed and the provider authorizes feeding. Option 4 gives inaccurate information.

==Question 9==
A child weighing 26 kg is prescribed maintenance intravenous fluids using the Holliday-Segar method. At what rate in milliliters per hour should the nurse set the pump? Record your answer to the nearest tenth.
# 54.2 mL/hr
# 62.5 mL/hr
# 67.5 mL/hr
# 108.3 mL/hr

'''Answer:''' 3. 67.5 mL/hr

''Rationale:'' Holliday-Segar: 100 mL/kg/day for the first 10 kg equals 1,000 mL; 50 mL/kg/day for the second 10 kg equals 500 mL; 20 mL/kg/day for the remaining 6 kg equals 120 mL. The total is 1,620 mL per 24 hours, or 67.5 mL/hr. Option 4 results from applying 100 mL/kg to the entire weight; the other distractors result from omitting a tier of the formula.

==Question 10==
The nurse prepares to administer digoxin to a 5-month-old with heart failure. The apical pulse, counted for one full minute, is 88 beats per minute. Which action is '''correct'''?
# Administer the dose and recheck the apical pulse in 1 hour.
# Hold the dose, document the finding, and notify the provider.
# Administer half the dose and reassess.
# Administer the dose only if the infant is feeding well.

'''Answer:''' 2. Hold the dose, document the finding, and notify the provider.

''Rationale:'' Digoxin is held in an infant when the apical rate is below approximately 90 to 110 beats per minute, and 88 is below that threshold. Bradycardia is often the earliest sign of digoxin toxicity in children, along with vomiting and anorexia. Option 1 administers a drug that may worsen bradycardia. Option 3 alters the prescribed dose. Option 4 uses an irrelevant criterion; in fact poor feeding would be an additional toxicity concern.

==Question 11==
A 7-month-old is admitted after a fall. Which assessment findings would lead the nurse to suspect '''increased intracranial pressure'''? '''Select all that apply.'''
# Tense, bulging anterior fontanel while the infant is quiet and supine with the head elevated
# High-pitched, shrill cry
# Widely separated cranial sutures with an enlarging head circumference
# Heart rate rising from 130 to 180 beats per minute with narrowing pulse pressure
# Poor feeding and repeated vomiting without diarrhea
# Setting-sun sign with the sclera visible above the iris

'''Answer:''' 1, 2, 3, 5, and 6.

''Rationale:'' In an infant with open sutures, rising intracranial pressure produces a bulging fontanel at rest, suture separation with abnormal head growth, a high-pitched cry, vomiting without diarrhea, poor feeding, and the setting-sun sign. Option 4 describes the wrong direction of change: the Cushing response to markedly elevated intracranial pressure is '''bradycardia''' with '''widening''' pulse pressure and irregular respirations, and it is a very late finding. Note that transient fontanel bulging during crying, coughing, or vomiting is normal, which is why option 1 specifies a quiet infant.

==Question 12==
A 6-year-old brought in for an asthma exacerbation initially had loud expiratory wheezes throughout all lung fields. After 20 minutes the nurse notes that the chest is now quiet on auscultation, the child is sitting forward, and the respiratory rate has increased with marked retractions. What does this change indicate?
# The bronchodilator has been effective and the child is improving.
# Airflow has become so limited that the child is in severe obstruction and impending respiratory failure.
# The child has developed a pneumothorax on the left side only.
# The child is anxious and is hyperventilating.

'''Answer:''' 2. Airflow has become so limited that the child is in severe obstruction and impending respiratory failure.

''Rationale:'' Wheezing requires turbulent airflow to generate sound. Loss of wheezing in a child whose work of breathing is increasing means too little air is moving to make noise, a "silent chest," and is an emergency requiring immediate escalation. Option 1 is the classic trap: improvement would be accompanied by decreased work of breathing and decreased respiratory rate, not increased retractions. Option 3 would produce unilateral, not global, changes. Option 4 dismisses objective distress.

==Question 13==
An 18 kg child in hypovolemic shock is prescribed a fluid bolus of 20 mL/kg of 0.9 percent sodium chloride. How many milliliters should the nurse infuse, and over what general time frame?
# 180 mL over 4 hours
# 360 mL infused rapidly, typically over 5 to 20 minutes, with reassessment afterward
# 900 mL over 1 hour
# 360 mL over 8 hours

'''Answer:''' 2. 360 mL infused rapidly, typically over 5 to 20 minutes, with reassessment afterward.

''Rationale:'' 18 kg x 20 mL/kg equals 360 mL. A resuscitation bolus is given rapidly, after which the nurse reassesses heart rate, capillary refill, mental status, and urine output to decide whether to repeat. Options 1 and 4 use maintenance-style rates that would not restore perfusion, and option 1 also miscalculates the volume. Option 3 both miscalculates and would risk fluid overload.

==Question 14==
A 12-year-old with sickle cell disease is admitted in vaso-occlusive crisis. Which prescriptions should the nurse question? '''Select all that apply.'''
# Apply cold packs to the affected joints
# Intravenous fluids at 1.5 times the maintenance rate
# Scheduled morphine by patient-controlled analgesia
# Meperidine every 4 hours as needed for pain
# Oxygen to maintain saturation above 94 percent
# Restrict oral fluids to 500 mL per day

'''Answer:''' 1, 4, and 6.

''Rationale:'' Cold causes vasoconstriction and worsens sickling, so warmth is applied instead. Meperidine is avoided in sickle cell disease because its metabolite normeperidine accumulates and lowers the seizure threshold, particularly with repeated dosing and renal impairment. Fluid restriction promotes sickling; hydration is a cornerstone of crisis management, which is why option 2 is appropriate. Scheduled or patient-controlled opioid analgesia is appropriate because pain in crisis is severe and continuous, and oxygen supports tissue oxygenation.

==Question 15==
A 15-month-old is admitted with suspected bacterial meningitis. Which nursing actions are appropriate? '''Select all that apply.'''
# Initiate droplet precautions immediately, before the organism is identified
# Maintain a quiet, dimly lit room and cluster nursing care
# Position the child with the head of the bed slightly elevated and the head midline
# Place the child in a room with a school-age child recovering from pneumonia for socialization
# Institute seizure precautions and monitor neurologic status frequently
# Discontinue isolation after 24 hours of effective antibiotic therapy

'''Answer:''' 1, 2, 3, 5, and 6.

''Rationale:'' Droplet precautions are started on suspicion, not after confirmation, and may be discontinued after 24 hours of effective antibiotic therapy. A quiet, dim environment and clustered care reduce stimulation that raises intracranial pressure. Slight head elevation with midline positioning promotes cerebral venous drainage. Seizures are a common complication, so precautions and frequent neurologic checks are required. Option 4 violates isolation and exposes another patient; it also disregards the need for a low-stimulation environment.

[[Category:Pediatric Nursing]]
[[Category:Registered Nurse (NCLEX-RN)]]
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