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CCRN-K Pediatric practice questions

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Question 1Clinical Judgment

A 4-year-old is admitted with a 3-day history of vomiting and diarrhea. Which assessment finding is the earliest and most reliable indicator of dehydration in this child?

  1. Decreased urine output with concentrated urine Correct answer.
  2. Dry mucous membranes
  3. Capillary refill of 2 seconds
  4. Sunken fontanelle

Explanation

In pediatric dehydration, oliguria with concentrated urine reflects the kidneys' attempt to conserve water and is one of the most reliable early signs of intravascular volume depletion. Other signs such as dry mucous membranes or delayed capillary refill appear later or are less specific. The fontanelle closes around 12-18 months, so it cannot be assessed in a 4-year-old.

Question 2Clinical Judgment

A 7-year-old with asthma is in respiratory distress. Which finding indicates impending respiratory failure rather than mild-to-moderate distress?

  1. Respiratory rate of 32 breaths/min
  2. Audible expiratory wheeze
  3. Silent chest with decreasing breath sounds Correct answer.
  4. Intercostal retractions

Explanation

A silent chest with diminishing breath sounds signals that air movement has become so poor that wheezing can no longer be produced, which is a late and ominous sign of impending respiratory failure. Wheezing, retractions, and tachypnea indicate distress but still reflect moving air. Escalating therapy and urgent provider notification are required.

Question 3Clinical Judgment

A 2-year-old is admitted with a suspected foreign body aspiration. Which clinical pattern most strongly supports this diagnosis?

  1. Inspiratory stridor that worsens with crying and improves with rest
  2. Sudden onset of choking and coughing that resolved, now with unilateral decreased breath sounds Correct answer.
  3. Productive cough with coarse rhonchi that clears with coughing
  4. Gradual onset of fever and bilateral crackles over 3 days

Explanation

A choking episode followed by asymmetric breath sounds is the classic presentation of an aspirated object lodged in a mainstem bronchus. The initial choking event may be missed, but unilateral findings reflect partial obstruction of one airway. Gradual febrile illness suggests pneumonia, and stridor suggests upper airway disease such as croup.

Question 4Clinical Judgment

A 6-month-old presents with a 2-day history of poor feeding and lethargy. Which vital sign finding should prompt immediate escalation in this infant?

  1. Temperature of 38.0 degrees C rectally
  2. Systolic blood pressure of 62 mmHg Correct answer.
  3. Respiratory rate of 40 breaths/min
  4. Heart rate of 130 beats/min

Explanation

Hypotension is a late and pre-arrest sign in infants, and a systolic pressure of 62 mmHg in a 6-month-old is below the expected minimum and indicates decompensated shock. Tachycardia, tachypnea, and fever are expected compensatory findings in a febrile infant. Hypotension requires immediate fluid resuscitation and provider notification.

Question 5Clinical Judgment

A 10-year-old with type 1 diabetes presents with abdominal pain, vomiting, and Kussmaul respirations. Which laboratory finding is most consistent with diabetic ketoacidosis?

  1. pH 7.45 with bicarbonate 26 mEq/L
  2. pH 7.20 with bicarbonate 10 mEq/L Correct answer.
  3. pH 7.38 with bicarbonate 24 mEq/L
  4. pH 7.50 with bicarbonate 30 mEq/L

Explanation

DKA is defined by metabolic acidosis with a low pH and low bicarbonate resulting from ketone accumulation. The Kussmaul breathing pattern is compensatory hyperventilation to blow off carbon dioxide. A pH of 7.20 with bicarbonate of 10 mEq/L fits this picture.

Question 6Clinical Judgment

A 3-year-old is admitted with a suspected epiglottitis. Which nursing action is the priority during initial assessment?

  1. Start an IV line for antibiotics
  2. Obtain a throat culture
  3. Inspect the throat with a tongue blade
  4. Keep the child calm in a position of comfort Correct answer.

Explanation

In suspected epiglottitis, any manipulation of the airway, including inspecting the throat, can precipitate complete obstruction. The priority is to keep the child calm and undisturbed while emergency airway support is arranged. IV access and cultures are deferred until the airway is secured.

Question 7Clinical Judgment

A 5-year-old with a ventriculoperitoneal shunt presents with headache, vomiting, and lethargy. Which assessment finding most suggests shunt malfunction with increased intracranial pressure?

  1. Sunsetting eyes and a bulging anterior fontanelle
  2. Increased urine output
  3. Hyperactive bowel sounds
  4. Bradycardia with hypertension and irregular respirations Correct answer.

Explanation

Cushing triad, consisting of bradycardia, hypertension, and irregular respirations, is a late sign of increased intracranial pressure from shunt malfunction. Sunsetting and a bulging fontanelle are also signs of ICP but the fontanelle is closed by age 5. Bradycardia with hypertension is the most concerning combination in this age group.

Question 8Clinical Judgment

A 2-year-old is receiving IV maintenance fluids. Which assessment finding is most concerning for fluid overload?

  1. Serum sodium of 138 mEq/L
  2. Weight gain of 0.5 kg over 24 hours Correct answer.
  3. Urine output of 1.5 mL/kg/hr
  4. Moist mucous membranes

Explanation

A weight gain of 0.5 kg (about 1.1 lb) in 24 hours represents roughly 500 mL of retained fluid and is a sensitive indicator of fluid overload in a toddler. Daily weights are the most reliable bedside measure of fluid balance. Moist mucous membranes and normal sodium suggest adequate or normal status.

Question 9Clinical Judgment

A 9-year-old with acute lymphoblastic leukemia has a platelet count of 12,000/mm3. Which nursing intervention is the priority?

  1. Administer aspirin for fever
  2. Use a soft toothbrush and avoid rectal temperatures Correct answer.
  3. Encourage vigorous ambulation
  4. Perform deep IM injections for medications

Explanation

With platelets of 12,000/mm3, the child is at high risk for spontaneous bleeding, so measures to prevent trauma to mucosa are essential. Soft toothbrushes and avoiding rectal routes reduce bleeding risk. Aspirin and IM injections increase bleeding risk and should be avoided.

Question 10Clinical Judgment

A 12-year-old with sickle cell disease presents with severe chest pain, fever, and a new infiltrate on chest x-ray. Which complication is most likely?

  1. Splenic sequestration
  2. Priapism
  3. Aplastic crisis
  4. Acute chest syndrome Correct answer.

Explanation

Fever, chest pain, and a new pulmonary infiltrate in a child with sickle cell disease indicate acute chest syndrome, a leading cause of death in this population. It requires urgent antibiotics, oxygen, and often transfusion. Splenic sequestration causes anemia and splenomegaly, not pulmonary infiltrates.

Question 11Clinical Judgment

A 4-year-old with nephrotic syndrome has periorbital edema and a serum albumin of 1.8 g/dL. Which finding should the nurse expect?

  1. Hyperlipidemia and proteinuria Correct answer.
  2. Hematuria with hypertension
  3. Elevated serum albumin
  4. Polyuria with dilute urine

Explanation

Nephrotic syndrome is characterized by the triad of proteinuria, hypoalbuminemia, and hyperlipidemia with edema. Massive protein loss in urine lowers serum albumin and triggers hepatic lipoprotein production. Hematuria with hypertension suggests nephritic syndrome instead.

Question 12Clinical Judgment

A 14-year-old with anorexia nervosa has a heart rate of 42 beats/min and a potassium of 2.9 mEq/L. Which complication is the greatest immediate concern?

  1. Delayed puberty
  2. Osteoporosis
  3. Cardiac dysrhythmia Correct answer.
  4. Constipation

Explanation

Bradycardia with hypokalemia in anorexia nervosa places the adolescent at high risk for life-threatening dysrhythmias, including torsades de pointes. Electrolyte derangements and cardiac effects are the most immediate threats. Osteoporosis and delayed puberty are chronic consequences rather than acute emergencies.

Question 13Clinical Judgment

A 6-year-old is admitted with a new diagnosis of type 1 diabetes. Which teaching point about hypoglycemia should the nurse include for the parents?

  1. Administer the next insulin dose early to stabilize glucose
  2. Give 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes Correct answer.
  3. Withhold all carbohydrate until glucose normalizes
  4. Give a dose of glucagon for any glucose below 100 mg/dL

Explanation

The rule of 15 is standard for treating mild hypoglycemia in a conscious child: give 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes. This prevents overtreatment and allows reassessment. Glucagon is reserved for severe hypoglycemia with altered consciousness or inability to swallow.

Question 14Clinical Judgment

A 1-year-old is admitted with a 2-day history of vomiting and diarrhea. Which finding indicates severe dehydration requiring immediate IV fluid bolus?

  1. Tear production with crying
  2. Lethargy with a capillary refill of 4 seconds Correct answer.
  3. Capillary refill of 1 second
  4. Moist mucous membranes

Explanation

Lethargy with a capillary refill of 4 seconds meets criteria for severe dehydration, which requires rapid isotonic fluid resuscitation. Prolonged capillary refill reflects poor peripheral perfusion. Moist membranes and tears indicate mild or no dehydration.

Question 15Clinical Judgment

A 10-year-old with a head injury has a Glasgow Coma Scale score that dropped from 14 to 9 over one hour. Which action is the priority?

  1. Encourage the child to sleep
  2. Elevate the head of the bed and notify the provider immediately Correct answer.
  3. Document the change and reassess in 4 hours
  4. Administer an antipyretic

Explanation

A decline in GCS to 9 indicates significant neurologic deterioration and possible herniation, requiring immediate provider notification and interventions to reduce intracranial pressure. Elevating the head of the bed promotes venous drainage. Waiting to reassess delays life-saving treatment.

Question 16Clinical Judgment

A 3-year-old presents with a barking cough, hoarse voice, and inspiratory stridor that worsens at night. Which intervention should the nurse anticipate first?

  1. Nebulized epinephrine and dexamethasone Correct answer.
  2. Antibiotic therapy
  3. Immediate intubation
  4. Chest physiotherapy

Explanation

The presentation is consistent with croup, which is treated with nebulized epinephrine for stridor at rest and a corticosteroid such as dexamethasone to reduce airway edema. Intubation is reserved for severe obstruction. Antibiotics are not indicated because croup is viral.

Question 17Clinical Judgment

A 2-year-old is brought in with a history of recurrent falls and a spiral fracture of the humerus. Which finding should raise the most concern for physical abuse?

  1. Injury inconsistent with the developmental stage and mechanism described Correct answer.
  2. A single fracture with a clear witness account
  3. Bruising over a bony prominence
  4. The child is comforted by the parent

Explanation

Fractures whose mechanism is inconsistent with the child's developmental stage, such as a spiral humerus fracture in a nonambulatory toddler, raise concern for abuse. Spiral fractures in young children can occur with twisting forces. A clear, consistent history lowers suspicion.

Question 18Clinical Judgment

A 5-year-old is receiving chemotherapy and has an absolute neutrophil count of 300/mm3. Which finding requires immediate provider notification?

  1. Temperature of 38.3 degrees C Correct answer.
  2. Hair loss
  3. Mild fatigue
  4. Appetite of 50% of meals

Explanation

A temperature of 38.3 degrees C in a child with an ANC below 500/mm3 meets criteria for febrile neutropenia, a medical emergency requiring cultures and empiric IV antibiotics. Fatigue, decreased appetite, and hair loss are expected chemotherapy effects. Prompt treatment reduces the risk of sepsis.

Question 19Clinical Judgment

A 7-year-old with a new diagnosis of acute glomerulonephritis has hypertension and hematuria. Which dietary instruction should the nurse provide?

  1. Restrict all fluids completely
  2. Encourage high-protein intake
  3. Increase potassium-rich foods
  4. Restrict sodium and monitor fluid balance Correct answer.

Explanation

Acute glomerulonephritis causes fluid retention and hypertension, so sodium restriction and careful monitoring of intake and output and daily weights are essential. Potassium may also need restriction if renal function is impaired. Complete fluid restriction is not routinely appropriate.

Question 20Clinical Judgment

A 12-year-old is admitted after a motor vehicle crash with a suspected spinal cord injury at C5. Which assessment finding indicates neurogenic shock?

  1. Hypertension with bradycardia
  2. Hypotension with tachycardia and cool extremities
  3. Hypotension with bradycardia and warm extremities Correct answer.
  4. Hypertension and tachycardia

Explanation

Neurogenic shock results from loss of sympathetic tone above the level of injury, producing hypotension with bradycardia and warm, dry extremities. Hypotension with tachycardia and cool skin suggests hypovolemic shock from bleeding. Distinguishing the two is critical because treatments differ.

Question 21Clinical Judgment

A 4-year-old with a tracheostomy is being suctioned. Which finding indicates the need to stop suctioning immediately?

  1. Heart rate decreasing from 110 to 60 beats/min Correct answer.
  2. Copious thin secretions
  3. Mild coughing during the pass
  4. Oxygen saturation of 96%

Explanation

Bradycardia during tracheal suctioning indicates vagal stimulation and hypoxia and requires stopping the procedure and providing oxygenation. Suctioning should be limited to 5-10 seconds per pass. Oxygen saturation of 96% and mild coughing are acceptable during suctioning.

Question 22Clinical Judgment

A 15-year-old with a history of depression is brought in after ingesting an unknown quantity of acetaminophen. Which laboratory value should be monitored most closely to guide treatment?

  1. Serum acetaminophen level with liver enzymes Correct answer.
  2. Serum amylase
  3. Serum creatinine only
  4. Serum calcium

Explanation

The acetaminophen level plotted on the Rumack-Matthew nomogram, along with liver enzymes, guides the use of N-acetylcysteine. Hepatic injury is the major toxicity. Amylase, calcium, and creatinine do not assess acetaminophen toxicity.

Question 23Clinical Judgment

A 6-year-old is receiving IV morphine for pain after surgery. Which finding should the nurse report immediately?

  1. Pain score of 3 out of 10
  2. Nausea without vomiting
  3. Respiratory rate of 8 breaths/min with sedation Correct answer.
  4. Itching at the IV site

Explanation

A respiratory rate of 8 with sedation in a child receiving opioids indicates respiratory depression, which may require naloxone. Opioids depress the central respiratory drive, so rate and depth must be monitored closely. Nausea and itching are common side effects that are managed but not immediately life-threatening.

Question 24Clinical Judgment

A 10-year-old with Duchenne muscular dystrophy is admitted with a respiratory infection. Which finding suggests the child is developing respiratory failure?

  1. Heart rate of 100 beats/min
  2. Increasing somnolence with a rising carbon dioxide level Correct answer.
  3. Coarse breath sounds that clear with coughing
  4. Temperature of 38.0 degrees C

Explanation

In Duchenne muscular dystrophy, respiratory muscle weakness leads to hypoventilation and carbon dioxide retention, which causes somnolence. A rising carbon dioxide level with increasing lethargy signals impending respiratory failure. Coarse breath sounds that clear with coughing are not evidence of failure.

Question 25Clinical Judgment

A 2-year-old is admitted with a burn covering 15% of the total body surface area. Which fluid resuscitation principle should the nurse apply?

  1. Withhold fluids until the child is awake
  2. Use 5% dextrose in water as the resuscitation fluid
  3. Give only maintenance fluids for the first 24 hours
  4. Use the Parkland formula with lactated Ringer's and begin within the first hour Correct answer.

Explanation

Burn resuscitation in children uses the Parkland formula with lactated Ringer's, and half of the calculated volume is given in the first 8 hours from the time of injury. Children also need maintenance fluids added because of their higher baseline requirements. Dextrose-containing solutions are not used for initial resuscitation.

Question 26Clinical Judgment

A 4-year-old is admitted with a suspected peanut allergy reaction and has audible inspiratory stridor with lip swelling. Which medication should the nurse anticipate administering first?

  1. Intravenous methylprednisolone
  2. Nebulized albuterol
  3. Intramuscular epinephrine Correct answer.
  4. Oral diphenhydramine

Explanation

Anaphylaxis with airway involvement is treated first with intramuscular epinephrine, which reverses bronchospasm and mucosal edema and stabilizes mast cells. Antihistamines and steroids are adjuncts given after epinephrine and do not relieve acute airway obstruction.

Question 27Clinical Judgment

A 7-year-old is brought to the clinic with a temperature of 38.9 C, sore throat, and a sandpaper-like rash with Pastia lines in the skin folds. Which finding should the nurse expect on assessment?

  1. Vesicles in a dermatomal distribution
  2. Strawberry tongue with circumoral pallor Correct answer.
  3. Slapped-cheek rash with lacy reticular pattern
  4. Koplik spots on the buccal mucosa

Explanation

The described presentation is scarlet fever, caused by group A streptococcus, which produces a sandpaper rash, Pastia lines, circumoral pallor, and a strawberry tongue. Prompt penicillin treatment prevents rheumatic fever and other complications.

Question 28Clinical Judgment

A 5-year-old is admitted with a new diagnosis of type 1 diabetes and a blood glucose of 480 mg/dL, pH 7.18, and deep respirations. Which order should the nurse question?

  1. Administer subcutaneous insulin glargine now Correct answer.
  2. Monitor serum potassium every two hours
  3. Start an insulin infusion per protocol
  4. Begin an isotonic IV fluid bolus

Explanation

In diabetic ketoacidosis, subcutaneous long-acting insulin is withheld until the acidosis resolves because it can cause unpredictable absorption and hypoglycemia when given during fluid and insulin infusion therapy. The other orders are standard components of DKA management.

Question 29Clinical Judgment

A 2-year-old is admitted with croup and receives nebulized racemic epinephrine. Which finding after treatment indicates the child needs continued close observation?

  1. A heart rate of 110 beats/min
  2. Mild subcostal retractions that improve with rest
  3. Return of stridor at rest two hours after the dose Correct answer.
  4. A hoarse cry that persists after treatment

Explanation

Racemic epinephrine temporarily reduces airway edema, but symptoms can rebound as the drug wears off, typically within two hours. Return of stridor at rest signals recurrent obstruction and requires continued monitoring and possible repeat dosing.

Question 30Clinical Judgment

A 10-year-old with asthma has a peak flow reading of 55% of personal best and is using accessory muscles. Which action should the nurse take next?

  1. Give a short-acting beta-agonist and reassess in 20 minutes Correct answer.
  2. Give the daily inhaled corticosteroid and reassess tomorrow
  3. Obtain a sputum culture before any treatment
  4. Encourage pursed-lip breathing and continue monitoring

Explanation

A peak flow at 55% of personal best with accessory muscle use indicates a moderate asthma exacerbation. Prompt administration of a short-acting beta-agonist with reassessment is the recommended first step, and the child may need systemic corticosteroids.

Question 31Clinical Judgment

A 6-year-old is receiving IV maintenance fluids and has a serum sodium of 128 mEq/L with new lethargy and a seizure. Which action should the nurse anticipate?

  1. Restrict all fluids immediately
  2. Administer oral sodium tablets
  3. Administer 3% hypertonic saline as ordered Correct answer.
  4. Give a bolus of 0.9% sodium chloride

Explanation

Symptomatic hyponatremia with neurologic signs such as lethargy and seizure requires careful correction with hypertonic saline to raise the sodium and reduce cerebral edema. Isotonic boluses can worsen dilutional hyponatremia in this setting.

Question 32Clinical Judgment

A 3-year-old is admitted with a suspected foreign body aspiration and has sudden coughing and unilateral decreased breath sounds. Which action should the nurse take first?

  1. Perform blind finger sweeps of the mouth
  2. Administer a dose of oral corticosteroids
  3. Keep the child calm and prepare for bronchoscopy Correct answer.
  4. Place the child supine and begin chest compressions

Explanation

A child with a suspected aspirated foreign body who is breathing should be kept calm and prepared for bronchoscopic removal. Blind finger sweeps can push the object deeper, and compressions are reserved for an unresponsive child.

Question 33Clinical Judgment

A 5-year-old with a ventriculoperitoneal shunt is admitted with abdominal pain and vomiting. Which finding should the nurse consider a sign of shunt infection?

  1. A temperature of 38.6 C with neck stiffness Correct answer.
  2. A soft abdomen with mild tenderness
  3. A single episode of vomiting after eating
  4. A headache relieved by lying flat

Explanation

Shunt infection presents with fever, meningismus, and signs of increased intracranial pressure, and may cause abdominal pain from infected cerebrospinal fluid in the peritoneum. Fever with neck stiffness is a red flag requiring urgent evaluation and CSF sampling.

Question 34Clinical Judgment

A 12-year-old is admitted with acute appendicitis and reports sudden relief of pain followed by diffuse abdominal pain and rigidity. Which action should the nurse take first?

  1. Administer an enema to relieve distention
  2. Apply a warm compress to the abdomen
  3. Notify the surgeon and prepare for emergency surgery Correct answer.
  4. Give oral fluids and reassess in one hour

Explanation

Sudden relief of localized pain followed by diffuse pain and rigidity suggests appendiceal rupture with peritonitis. The nurse should notify the surgeon immediately and prepare for emergency surgery while maintaining NPO status and IV access.

Question 35Clinical Judgment

A 9-year-old with cystic fibrosis is admitted with a pulmonary exacerbation. Which intervention should the nurse schedule first?

  1. Pancreatic enzymes with a high-fat meal
  2. Airway clearance therapy before inhaled antibiotics Correct answer.
  3. Chest physiotherapy after breakfast only
  4. Inhaled antibiotic after airway clearance

Explanation

Airway clearance should precede inhaled antibiotics so that secretions are removed and the drug reaches distal airways. This sequencing improves drug delivery and is a core component of cystic fibrosis pulmonary care.

Question 36Clinical Judgment

A 4-year-old is admitted with a burn and the nurse calculates the child's fluid needs using the Parkland formula. Which statement reflects correct application in children?

  1. Urine output goals are lower in children than in adults
  2. Colloid is always preferred over crystalloid in pediatric burns
  3. Children may need additional maintenance fluid beyond the burn resuscitation volume Correct answer.
  4. The Parkland formula fully accounts for maintenance needs in children

Explanation

The Parkland formula estimates only burn-related resuscitation needs and does not include maintenance fluid, so children require additional maintenance volume. Children also have higher baseline fluid needs because of greater body surface area relative to weight.

Question 37Clinical Judgment

A 14-year-old with a new diagnosis of major depressive disorder is started on fluoxetine. Which teaching point is most important for the nurse to include?

  1. Stop the medication as soon as mood improves
  2. Report any increase in suicidal thoughts or behavior promptly Correct answer.
  3. Expect full therapeutic effect within three days
  4. Take the medication only when feeling sad

Explanation

Antidepressants can increase suicidal ideation in adolescents, especially early in treatment, so close monitoring and prompt reporting of worsening thoughts are essential. The full antidepressant effect typically takes several weeks, and abrupt discontinuation can cause withdrawal.

Question 38Clinical Judgment

A 7-year-old is admitted with acute glomerulonephritis and has a blood pressure of 130/90 mm Hg with a headache. Which nursing action is priority?

  1. Ambulate the child frequently
  2. Administer the prescribed antihypertensive and monitor blood pressure Correct answer.
  3. Encourage a high-protein diet
  4. Increase oral fluid intake

Explanation

Hypertension with headache in acute glomerulonephritis raises concern for hypertensive encephalopathy and seizures. Lowering the blood pressure with prescribed medication and monitoring closely is the priority.

Question 39Clinical Judgment

A 2-year-old is brought in with a barking cough and stridor at rest. Which assessment finding is most concerning?

  1. Drooling with an inability to swallow Correct answer.
  2. Inspiratory stridor that improves with crying
  3. A hoarse voice
  4. A low-grade fever

Explanation

Drooling with inability to swallow suggests epiglottitis or another supraglottic obstruction, which threatens the airway. Croup typically causes a barking cough and hoarseness without drooling.

Question 40Clinical Judgment

A 10-year-old with sickle cell disease is admitted with a vaso-occlusive pain crisis. Which intervention should the nurse include in the plan of care?

  1. Encourage strict bed rest without movement
  2. Encourage oral fluids and administer scheduled analgesics Correct answer.
  3. Apply cold packs to painful extremities
  4. Restrict fluids to prevent overload

Explanation

Hydration reduces blood viscosity and sickling, and scheduled analgesics control pain and prevent crisis escalation. Cold packs cause vasoconstriction and worsen sickling, so warmth is preferred.

Question 41Clinical Judgment

A 6-year-old is admitted with bacterial meningitis. Which isolation precaution should the nurse implement?

  1. Airborne precautions for the entire hospitalization
  2. Droplet precautions until 24 hours of effective antibiotics Correct answer.
  3. Standard precautions only
  4. Contact precautions only

Explanation

Bacterial meningitis caused by Neisseria meningitidis or Haemophilus influenzae requires droplet precautions until 24 hours of effective antibiotic therapy. Airborne precautions are not required for these organisms.

Question 42Clinical Judgment

A 1-year-old is admitted with severe dehydration and receives a 20 mL/kg isotonic fluid bolus. Which finding indicates the bolus was effective?

  1. Heart rate of 180 beats/min
  2. Capillary refill less than two seconds Correct answer.
  3. Sunken fontanel
  4. Urine output of 0.5 mL/kg/hr

Explanation

Improved capillary refill indicates restored peripheral perfusion after fluid resuscitation. Urine output of 0.5 mL/kg/hr is below the pediatric target of 1 to 2 mL/kg/hr, and a sunken fontanel and tachycardia indicate ongoing dehydration.

Question 43Clinical Judgment

A 13-year-old is admitted with a head injury and is receiving hypertonic saline. Which assessment finding should the nurse report immediately?

  1. Serum sodium of 145 mEq/L
  2. A Glasgow Coma Scale score of 15
  3. Pupils equal and reactive to light
  4. A new onset of diabetes insipidus with high urine output Correct answer.

Explanation

Diabetes insipidus after head injury signals damage to the posterior pituitary or hypothalamus and can cause rapid hypovolemia and hypernatremia. It requires immediate reporting and treatment with desmopressin and fluid replacement.

Question 44Clinical Judgment

A 3-year-old is admitted with a suspected femur fracture after a fall. Which finding should prompt the nurse to screen for child abuse?

  1. The child cries during the physical examination
  2. The parents provide a consistent history
  3. The mechanism of injury does not match the developmental stage Correct answer.
  4. The child has a single, well-explained injury

Explanation

Injuries inconsistent with the child's developmental abilities or the reported mechanism raise concern for abuse. A single, well-explained injury with a consistent history is less concerning.

Question 45Clinical Judgment

A 5-year-old with leukemia has an absolute neutrophil count of 200/mm3 and a temperature of 38.4 C. Which action should the nurse take first?

  1. Give acetaminophen and reassess in four hours
  2. Obtain blood cultures and administer prescribed antibiotics Correct answer.
  3. Place the child in a negative-pressure room
  4. Restrict all visitors indefinitely

Explanation

A febrile neutropenic child is at high risk for sepsis, so blood cultures should be drawn and broad-spectrum antibiotics started promptly, ideally within one hour. Antipyretics alone delay essential treatment.

Question 46Clinical Judgment

A 12-year-old with a spinal cord injury at C5 has a sudden severe headache, profuse sweating, and a blood pressure of 160/100 mm Hg. Which action should the nurse take first?

  1. Sit the child upright and check for bladder distention Correct answer.
  2. Administer a prescribed antihypertensive and wait
  3. Apply a heating pad to the abdomen
  4. Place the child flat and give a fluid bolus

Explanation

These findings indicate autonomic dysreflexia, which is triggered by noxious stimuli such as bladder distention. The first action is to sit the child upright and identify and remove the trigger, which lowers blood pressure.

Question 47Clinical Judgment

A 4-year-old with a tracheostomy is receiving suctioning and the heart rate drops from 110 to 60 beats/min. Which action should the nurse take first?

  1. Increase suction pressure and reattempt
  2. Instill normal saline to loosen secretions
  3. Stop suctioning and ventilate with 100% oxygen Correct answer.
  4. Continue suctioning to clear the airway

Explanation

Bradycardia during suctioning indicates vagal stimulation or hypoxia, so suctioning should stop immediately and the child should be oxygenated. Suctioning should be limited to 5 to 10 seconds to prevent this complication.

Question 48Clinical Judgment

A 15-year-old is admitted after an acetaminophen overdose. Which laboratory value is most important for the nurse to monitor?

  1. Serum calcium
  2. Serum creatinine
  3. Serum alanine aminotransferase Correct answer.
  4. Serum amylase

Explanation

Acetaminophen toxicity causes hepatic necrosis, so liver enzymes such as alanine aminotransferase are the key markers to monitor. N-acetylcysteine should be given as early as possible after ingestion.

Question 49Clinical Judgment

A 6-year-old is receiving IV morphine after surgery and has a respiratory rate of 8 breaths/min with sedation. Which action should the nurse take first?

  1. Encourage the child to take deep breaths
  2. Give the next scheduled morphine dose
  3. Stop the opioid and administer naloxone as ordered Correct answer.
  4. Document the finding and reassess in 30 minutes

Explanation

A respiratory rate of 8 breaths/min with sedation indicates opioid-induced respiratory depression. The nurse should stop the opioid and administer naloxone while supporting ventilation.

Question 50Clinical Judgment

A 10-year-old with Duchenne muscular dystrophy is admitted with pneumonia and has a weak cough. Which intervention should the nurse prioritize?

  1. Assist with airway clearance using cough-assist devices Correct answer.
  2. Administer a cough suppressant
  3. Restrict oral fluids
  4. Encourage strict bed rest

Explanation

Children with Duchenne muscular dystrophy have weak cough and respiratory muscles, so assisted airway clearance is essential to prevent atelectasis and respiratory failure. Cough suppressants and immobility worsen secretion retention.