NCLEX Exam 6

A 6-month-old infant receives a diphtheria, tetanus, and pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which is the appropriate response by the nurse?

"Apply an ice pack to the injection site."

The nurse is reinforcing the teaching of parents of a diabetic child on the differences between type 1 and type 2 diabetes mellitus. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"The onset of diabetes is sudden with type 1." "Type 2 diabetes can often be managed with diet only." "Three symptoms of type 1 diabetes are polyuria, polydipsia and polyphagia."

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?

"The symptoms increase in severity after the rash appears."

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

"We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."

The nurse is providing discharge teaching regarding skin care to a new mother of a 2-day-old infant. Which statements by the mother demonstrate an understanding of how to care for the infant's skin? Select all that apply.

"We will apply ointments containing zinc oxide to the baby's bottom to prevent diaper rash." 3. "To prevent diaper rash, we will change our baby's diaper as soon as he has pooped or peed."

A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements should the nurse make to the child about the cushingoid appearance? Select all that apply.

"Which manifestations of this condition do you find most troublesome?" "The signs/symptoms are lessened by taking the prednisone every other day instead of daily." "The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued."

The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be appropriate? Select all that apply.

"You feel like there's nothing else you can do to cure your acne." 5. "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."

Which test would the nurse anticipate for a teenage client who has been treated for vaginal Candida infections repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?

Blood glucose level

A child is hospitalized with Rocky Mountain spotted fever (RMSF). The health record reveals documentation that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the primary health care provider's prescriptions and anticipates that which medication should be prescribed?

Doxycycline

A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breastfeeding the infant and asks the nurse if breastfeeding can be continued. Which response is appropriate?

"Breastfeeding can continue, but your breasts should also be treated with nystatin."

An adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse should instruct the adolescent to take which action?

Eat six graham crackers or drink a cup of orange juice before practice or game time.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

A mother brings her 15-month-old child to the primary health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, the nurse might suspect that the child has which communicable disease?

Fifth disease

The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?

Forty-eight hours after using the antibiotic ointment

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?

Give the child 6 oz of a regular cola drink.

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dL. Which is the appropriate intervention?

Give the child a glass of fruit juice.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.

Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs

An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.

Glucose level at 2 am of 65 mg/dL

A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student should include which correct item in the discussion?

HIV virus attacks the immune system by destroying T lymphocytes.

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?

Insertion of a Foley catheter

Which criterion should the nurse determine are characteristics of scabies? Select all that apply.

It appears as burrows or fine, grayish-red lines. It is transmitted by close personal contact with an infected person. It is endemic among schoolchildren and institutionalized populations. Household members and contacts of the infected child need to be treated at the same time that the child is being treated.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative.

A child seen in the clinic is found to have rubeola (measles) and the mother asks the nurse how to care for the child. Which instruction should the nurse provide to the mother?

Keep the child in a room with dim lights.

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action?

Keeping the child uncovered to assist in reducing the fever

The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?

Level of consciousness

The nurse is assisting a school-age client with type 1 diabetes to follow an appropriate diet. Which recommendations should the nurse make for this client? Select all that apply.

Limit concentrated sweets. 3. Consume snacks between meals and at bedtime. 4. Plan to eat a larger snack during active times of the day.

A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?

Macular rash on the trunk and scalp

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as which level of dehydration?

Moderate dehydration

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents?

Notify the pediatrician if the child develops abdominal or left shoulder pain.

The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?

Nuchal rigidity

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?

Obtain a blood glucose reading.

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply.

Oliguria Slightly sunken fontanels Very dry, mucous membranes

The nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which information in the conference?

PKU results in central nervous system (CNS) damage.

In planning care for a child with contact dermatitis, which concern is the highest priority for the child?

Pain

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?

Pastia's sign

A camp nurse is reinforcing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents that if a tick is found to do which action first?

Suffocate the tick with a substance such as nail polish.

The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include when reinforcing the teaching? Select all that apply.

Sweating Dizziness Trembling

The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.

The 6-month old with bronchopulmonary dysplasia The 1-year-old client taking corticosteroids

n infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which indicates to the nurse that the parents need further teaching about the care of their HIV-positive infant?

The parents plan to use rice cereal to help with watery stools when they occur.

A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last diphtheria, tetanus, and pertussis (DTaP) vaccination. Which instructions should the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?

To administer an appropriate dose of Tylenol 45 minutes before the appointment

The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points should the nurse include in the session? Select all that apply.

Tuck pant legs into socks. Wear closed shoes when hiking. Apply insect repellent containing DEET. Cover the ground with a blanket when sitting.

The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?

Urinary output is increased.

A primary health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child should check which highest priority item before administration of the potassium?

Urine output

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?

White sacs attached to the hair shafts in the occipital area

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

Drink a half a cup of orange juice before soccer practice.

The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine?

Allergy to eggs

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?

"I understand this whooping cough is viral and I have to let it run its course."

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse reinforce to the mother to prevent the transmission of the disease?

"Disease transmission is unknown."

The nurse determines that an adolescent client with diabetes mellitus needs further teaching about A1c levels and their purpose if the client made which statement when told that a level will be drawn?

"I already had a complete blood cell count drawn an hour ago, so this test is not necessary."

Griseofulvin is prescribed for a child with tinea capitis. The nurse reinforces instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further teaching?

"I need to administer the medication 2 hours before meals."

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and reinforces instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures?

"I need to call the primary health care provider if my child complains of abdominal pain or left shoulder pain."

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching?

"I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out."

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?

"I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."

The nurse is reinforcing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication?

"I need to wash the sites gently before I apply the medication."

The clinic nurse is reinforcing instructions to an adolescent with type 1 diabetes about administration of insulin. Which statements by the adolescent indicate the need for further teaching? Select all that apply.

"I should give my injections only in my thighs." "I should place any unopened insulin vials in the freezer."

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?

"I understand that I need to leave the scabicide on for 4 hours before washing it off."

The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session the nurse notes that one girl is scratching her head. On inspection, the nurse determines that the child has pediculosis capitis. When reinforcing instructions to the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition?

"I will call a carpet cleaning service to clean all my carpets in the house."

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching?

"I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?

"I will not let my child play with other children who have the flu unless they are taking acetaminophen."

The nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?

"Is the child allergic to any antibiotics?"

The nurse is teaching first aid measures to a group of adolescents about appropriate treatment for burns. The nurse should anticipate the need for further teaching when one of the adolescents makes which statement?

"It is appropriate to place butter on the burn."

The nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further teaching?

"Lesions are most often located on the arms and chest."

A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?

"My child will need to be treated with oral antibiotics."

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?

"PKU primarily affects the gastrointestinal system."

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease?

"The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."

The nurse reinforces instructions regarding the use of permethrin 1% to the parents of a child who has been diagnosed with pediculosis capitis. Which statements by the parents indicate they understand the instructions? Select all that apply.

"The hair should not be shampooed for 24 hours after treatment." 3. "The medication can be obtained over the counter in a local pharmacy." 5. "The medication is applied to the hair after shampooing, left on for 5 to 10 minutes, and then rinsed out."

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for what?

0.9% normal saline IV infusion

The nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and should expect to note which finding?

An elevated thyroid-stimulating hormone (TSH) level

A nursing student is asked to administer a tepid bath to a child with a fever. The student should avoid which action when performing this procedure?

Applies alcohol-soaked cloths over the child's body

A topical corticosteroid is prescribed by the primary health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

Apply an ice pack to the injection site.

The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply.

Atenolol Propranolol Methimazole

The nurse is planning care for a hospitalized child with syndrome of inappropriate antidiuretic hormone (SIADH). The primary health care provider has prescribed that the 24-hour fluid maintenance for the child weighing 12 kg be at ¾ of the maintenance. Using the formula shown (refer to figure), which volume of fluid should the nurse plan as the 24-hour maintenance for this child?

825 mL

The school nurse notes that the child has a rash and suspects that it is caused by erythema infectiosum (fifth disease). The nurse bases this determination on the observation that the rash results in which appearance?

A "slapped-face" appearance

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted?

A decrease in urine output to 0.5 mL/kg/hr

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

The nurse is planning care for a child with type 1 diabetes. Which items should the nurse plan to use to treat an early mild hypoglycemic episode? Select all that apply.

Candy Orange juice Glucose tablets

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? Select all that apply.

Contact Airborne

The nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. How should the nurse plan to administer the vaccine?

Subcutaneously in the outer aspect of the upper arm

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

DTaP, Hib, IPV, pneumococcal vaccine (PCV)

The nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to take which action?

Delay the immunization.

The nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the primary health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which should the nurse expect to note in the child?

Petechiae spots located on the palate

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse should take which action to provide safety for all children on the unit?

Place the infected child and any immunocompromised children in isolation.

The nurse has just administered ibuprofen to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?

Remove excess clothing and blankets from the child.

The nurse in a primary health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which instruction should the nurse reinforce to the mother?

Remove the stinger by carefully scraping it out horizontally.

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?

Respiratory disease caused by a virus involving the parotid gland

The nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? Select all that apply.

Siblings may also need treatment. Grooming items such as combs and brushes should not be shared. Launder all the bedding and clothing in hot water and dry on high heat. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction?

½ cup of fruit juice