These questions are one of the NCLEX prep samples for Physiological Integrity. This post has a 25 set of questions with the accompanying answers and rationale located at the bottom. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.
1. A child with a ankle sprain is being discharged from the emergency room. To promote tissue healing and relieve discomfort, nurse Julia instructs the parents to:
a. Apply cold compress to the affected area
b. Keep the extremity in a dependent position
c. Apply a hot compress to the affected area
d. Restrict activity until there is no swelling to the affected area
2. A ten month old infant with acquired immunodeficiency syndrome (AIDS) is admitted with pneumonia in order to receive intravenous antibiotic therapy. In addition to the antibiotics, Dr. Suarez orders all of the following for the infant. Which of these orders should the nurse question?
a. Vital signs with rectal temperature every four hours
b. Flush the intravenous saline lock after meds and p.r.n.
c. Check oxygen saturation (oximetry) every shift and p.r.n.
d. Obtain a CBC (complete blood cell count) with differential
3. A 12 year old client with asthma is instructed in the use of a peak flow meter for improved home management of the disease. In teaching the client, nurse Catherine is guided by the knowledge that the purpose of the peak flow meter is to enable the client to:
a. Detect airway obstruction before the onset of manifestations
b. Take deep breaths every one to two hours
c. Accurately adjust the delivery rate of oxygen
d. Breathe deeper when using metered dose inhalers
4. The initial nursing action to promote ventilation for a child in shock is to:
a. Establish an airway
b. Assess the respiratory rate
c. Obtain arterial blood gases (ABGs)
d. Monitor the blood pressure
5. Which of the following statements made by a mother of an-eight-month-old infant would concern the nurse? My baby:
a. Cries all day at the sitter’s
b. Is teething and therefore running a fever
c. Doesn’t pay much attention to loud noises
d. Throws both arms forward when held
6. While observing a two-year-old girl recently admitted to the hospital, nurse Carmen becomes concerned because the child:
a. Is not yet potty trained
b. Replies no to every question
c. Cannot share toys
d. Recognizes four to six words
7. Nurses are required to report any suspected child abuse. The most important observation by nurse Carmina can be use as a basis for reporting suspected abuse is:
a. Inconsistency between the history and the injury
b. Visible bruises on the child
c. A caregiver brings the child to the clinic instead of a parent
d. The child is crying inconsolably while being held by the parent
8. Nurse Perry is preparing to administer digoxin (Lanoxin), to a hospitalized five year old. Which of the following is the minimal apical pulse rate the nurse should obtain prior to administering this medication:
9. Nurse Loraine knows children who have received diphtheria, tetanus, and pertussis (DPT) injections on a regular basis have obtained which of the following:
a. Naturally acquired active immunity
b. Artificially acquired active immunity
c. Naturally acquired passive immunity
d. Artificially acquired passive immunity
10. A 12-year-old client has a peripherally inserted central catheter (PICC) line inserted for home intravenous therapy. To confirm proper PICC line placement, which of the following will nurse Gretchen anticipate doing immediately following insertion?
a. Aspirating for venous blood return
b. Auscultating the site for a bruit
c. Taking the child for a chest x-ray
d. Measuring the catheter’s external length
11. Which of these actions, if taken by nurse Angelica would best relieve a hospitalized toddler’s anxiety if the parents have to leave the hospital?
a. Ask the parents to leave one of their possessions with the toddler
b. Place the toddler in a room with a two year old
c. Place the toddler in a room near the nurses’ station
d. Have a hospital volunteer visit the toddler
12. Nurse Tony knows which of the following is an inappropriate statement regarding preterm infant’s need for large amounts of fluids? The preterm infant:
a. Is unable to concentrate urine
b. Has a large body water content
c. Requires extra essential amino acids
d. Has large amounts of evaporation of body water
13. A child with asthma is brought to the emergency room with audible wheezing and difficulty breathing. The initial action by the nurse is to:
a. Give epinephrine intramuscularly
b. Place the child in a mist tent
c. Administer aminophylline intravenously
d. Provide oxygen via mask
14. Nurse Lucy understands that a toddler should begin to scribble spontaneously with a crayon at what age?
a. Twelve months
b. Eighteen months
c. Twenty-four months
d. Twenty-eight months
15. A ten-year-old client has been diagnosed with sickle cell anemia (SCA). During discharge teaching, which of the following interventions does the nurse need to stress to the child and the family?
a. Increase fluid intake
b. Increase fat intake
c. Closely monitor bowel movements
d. Serve leafy green vegetable daily
16. A child is found to have a mildly elevated serum lead level. Because of this, nurse Alma instructs the parents in the need to provide the child with a diet that is:
a. High in iron
b. Low in calcium
c. High in fat
d. Low in fiber
17. A mother brings her 4-month-old to the clinic for a wellness checkup. Which immunizations should the infant receive?
a. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP), inactivated polio virus (IPV), rotavirus, and measles-mumps-rubella (MMR)
b. Haemophilus influenzae type B (Hib), rotavirus, DTaP, and IPV
c. DTaP, IPV, Hib, and hepatitis B
d. DTaP, hepatitis B, Hib, and varicella
18. An infant, age 6 months, is brought to the clinic for a well-baby visit. The mother reports that the infant weighed 7 lb (3.2 kg) at birth. Based on the nurse’s knowledge of infant weight gain, which current weight would be within the normal range for this infant?
a. 14 lb (6.4 kg)
b. 21 lb (9.5 kg)
c. 10.5 lb (4.8 kg)
d. 17.5 lb (7.9 kg)
19. Nurse Danny is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used when a child is:
a .under age 3
b. over age 3
c. critically ill and under age 3
d. critically ill and over age 3
20. A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child’s ear problems, nurse Louie should ask the parent:
a. Does your child’s ear hurt?
b. Does your child have any hearing problems?
c. Does your child tug at either ear?
d. “Does anyone in your family have hearing problems?
21. A toddler has a temperature above 101° F (38.3° C). The physician prescribes acetaminophen (Tylenol), 120 mg suppository to be administered rectally every 4 to 6 hours. However, nurse Becky should not administer this rectal medication if the child has:
22. The mother of a 4-year-old child tells the nurse that her child is a very poor eater. What is the nurse’s best recommendation for helping her increase her child’s nutritional intake?
a. Allow the child to feed herself
b. Use specially designed dishes for children — for example, a plate with the child’s favorite cartoon character
c. Only serve the child’s favorite foods
d. Allow the child to eat at a small table and chair by herself
23. Nurse Jamie is concerned about another nurse’s relationship with the members of a family and their ill preschooler. Which of the following behaviors would be most worrisome and should be brought to the attention of the nurse-manager?
a. The nurse keeps communication channels open among herself, the family, physicians, and other health care providers
b. The nurse attempts to influence the family’s decisions by presenting her own thoughts and opinions
c. The nurse works with the family members to find ways to decrease their dependence on health care providers
d. The nurse has developed teaching skills to instruct the family members so they can accomplish tasks independently
24. A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child’s parents ask the nurse whether anything could have prevented this disorder. Which intervention is most effective in preventing rheumatic fever?
a. Immunization with the hepatitis B vaccine
b. Isolation of individuals with rheumatic fever
c. Use of prophylactic antibiotics for invasive procedures
d. Early detection and treatment of streptococcal infections
25. A 16-year-old client sustains a severe head injury in a motor vehicle accident. He’s admitted to the neurologic unit and subsequently develops neurogenic diabetes insipidus. Dr. Fernandez prescribes vasopressin (Pitressin), 5 units subcutaneously (S.C.) twice a day. When vasopressin is given S.C., it begins to act within:
a. 5 minutes
b. 1 hour
c. 2 hours
d. 4 hours