NCLEX Question of the day

A nurse should expect a 3-year-old child to be able to perform which action?: a) Ride a tricycle b) Tie his shoelaces c) Roller-skate d) Jump rope

CORRECT ANSWER a) Ride a tricycle Reason: The nurse should expect the child to ride a tricycle because, at age 3, gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to tie shoelaces and the gross motor skills required for roller-skating and jumping rope develop around age 5.

The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal?: a) Soft. b) Egg-shaped. c) Spongy. d) Lumpy.

CORRECT ANSWER b) Egg-shaped. Reason: Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the physician.

Which of the following measures should the nurse include in the care plan for a child who is receiving high-dose methotrexate (amethopterin) therapy?: a) Keeping the child in a fasting state. b) Obtaining a white blood cell (WBC) count. c) Preparing for radiography of the spinal canal. d) Collecting a specimen for urinalysis.

CORRECT ANSWER b) Obtaining a white blood cell (WBC) count. Reason: Methotrexate is not highly toxic in low doses but may cause severe leukopenia at higher doses. It is customary and recommended for blood tests to be done before therapy to provide a baseline from which to study the effects of the drug on WBC count. Maintaining a fasting state, radiography of the spinal canal, and urinalysis are not necessary when this drug is administered.

A physician has ordered penicillin G potassium (Pfizerpen), I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?: a) Holding the penicillin G potassium and charting that it was held because the client is allergic b) Administering the penicillin G potassium and staying alert for any reaction c) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin d) Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction

CORRECT ANSWER c) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin Reason: The nurse should hold the penicillin G potassium, even if the client isn't sure he's allergic to penicillin, and notify the physician so he may order a different antibiotic. Many clients can't act as their own advocates; they rely on nurses to protect their rights. An allergy to penicillin G potassium is suspected, but not confirmed. Administering penicillin G potassium could cause a life-threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.

An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents: a) Have the right to review a minor's medical records until high school graduation. b) Have the right to review a minor's medical record if they are responsible for the payment. c) May not view the medical record, but may learn of the visit through the insurance bill. d) May not view the minor's medical record or the insurance bill.

CORRECT ANSWER c) May not view the medical record, but may learn of the visit through the insurance bill. Reason: Under HIPAA, 18-year-olds have the right to medical privacy and their medical records may not be disclosed to their parents without their permission. However, the adolescent must be made aware of the fact that information is sent to third party payers for the purpose of reimbursement. Those payers send the primary insurer, in this case the parent, a statement of benefits. HIPAA protects the right to medical privacy of all 18-year-olds regardless of their educational status. Even if parents are responsible for payment, they may not view the patient's chart without the consent of the adolescent.

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first? : a) Ask another nurse to verify the findings. b) Notify the primary care provider of the findings. c) Raise the head of the bed. d) Administer an antipyretic.

CORRECT ANSWER c) Raise the head of the bed. Reason: Signs such as a decrease in the level of consciousness, bradycardia, hypertension, irregular respirations, and a tense fontanel strongly suggest increased intracranial pressure. The first action should be to attempt to lower the pressure by raising the head of the bed, which should improve venous return and decrease the pressure. Asking another nurse to verify the findings is unnecessary because temperature, pulse, and respirations are fairly objective data and not subject to interpretation. Additionally, asking for verification would waste valuable time. After elevating the infant's head by raising the bed, the nurse can notify the primary care provider and administer the antipyretic.

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: a) nausea and vomiting. b) dyspnea and cyanosis. c) fatigue and weakness. d) thrush and circumoral pallor.

CORRECT ANSWER c) fatigue and weakness. Reason: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.