ATI RN
Pediatric NCLEX Questions Questions
Question 1 of 5
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
Correct Answer: C
Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.
Question 2 of 5
while gently abducting the hips, the nurse feels the femoral head slip into the acetabulum. the nurse documents this finding as a positive:
Correct Answer: C
Rationale: Ortolani's sign is a physical exam maneuver used to detect congenital hip dislocation in infants. When performing Ortolani's sign, the nurse gently abducts the hips and feels the femoral head slipping back into the acetabulum. This is considered a positive finding and suggests the presence of hip dysplasia. Barlow's test, on the other hand, involves gently adducting the hip to feel for instability and potential dislocation. Jackson's sign is a maneuver for detecting hip dislocation by observing leg length discrepancy. Trendelenburg's sign is a test for hip abductor weakness. Hematuria is the presence of blood in urine and is not related to hip exams or signs.
Question 3 of 5
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
Correct Answer: C
Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.
Question 4 of 5
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.
Question 5 of 5
The nurse will assess a loss of ability in which of the following areas?
Correct Answer: A
Rationale: The nurse will assess a loss of ability in the area of balance. Balance is an essential component of the physical function that allows individuals to maintain an upright posture and stability during movement. A loss of balance can significantly impact a person's mobility, coordination, and safety. Nurses often assess balance as part of their evaluations to identify any impairments that may affect a patient's independence and daily activities.