NCLEX Questions
An enterostomy nurse is providing an in-service session on caring for colostomies. Which statement by a nurse indicates the need for further teaching?
"I can make a small pin hole in the bag to let the gas out, so I don't have to change the appliance frequently." The nurse requires additional teaching if she states that she can make a hole in the drainage bag to let gas out. Any hole in the drainage bag, no matter how small, will destroy the odor-proof seal. Removing or unclamping the bag is the only appropriate method for releasing the gas accumulated in the bag. Odor-relieving tablets, usually made of charcoal, can be placed in the bag to help with the odor.
The nurse is caring for a 5-year-old child with a congenital heart defect. The nurse is reviewing with the parents the actions that would be necessary if the child experiences cardiopulmonary arrest and needs resuscitation. Which of the following statements by the parents indicate to the nurse that the teaching has been understood? Select all that apply.
"I have to use compressions to circulate the blood." • "I will give two breaths for every 30 compressions." • "I will check for responsiveness before starting CPR."
The health care provider (HCP) has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
"I will get a prescription for a lubricant with numbing medicine to make the procedure more comfortable."
Which statement indicates that a client with esophageal reflux disorder understands the dietary teaching?
"I won't drink any carbonated drinks." Carbonated drinks should be avoided when a client has esophageal reflux disorder, because the carbonation causes increased esophageal pressure, which leads to increased reflux. Caffeine will cause increased acid production, as will lemonade. All of these drinks should be avoided
The parent of a preschool-age child has been told the child has sleep terrors. Which of the following statements should the nurse include when teaching the parents about sleep terrors?
"It is appropriate to intervene only if it is necessary to protect the child."
After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which age?
7 years Children younger than 7 years of age do not have the manual dexterity needed for tooth brushing. Therefore, parents need to help with this task until that time.
Which client requires immediate nursing intervention? The client who:
A rigid, boardlike abdomen is a sign of peritonitis, a possibly life-threatening condition.
A nurse is preparing a 4-year-old child for surgery. Which is the best nursing intervention?
Allowing the child to wear underwear if desired.
A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which of the following problems is associated with cirrhosis of the liver?
Ascites related to portal hypertension Explanation: The jaundice is a result of inability of the liver to break down the end products from red blood cells, resulting in elevated bilirubin levels. Small bowel ulcerations do not occur as a result of elevated bilirubin levels and are not problems commonly associated with cirrhosis.
A nurse is obtaining the history of a child, age 4. Which question best evaluates the child's developmental status?
Can you ride a tricycle?" Explanation: Asking the child if he can ride a tricycle best helps evaluate the child's developmental status because a 4-year-old child should be able to perform such an action
The nurse planning care for a child in vaso-occlusive crisis because of sickle cell disease should include increasing fluid intake in the list of interventions because:
Decreased blood viscosity prevents the sickling process. Treatment of a child in vaso-occlusive crisis from sickle cell disease includes measures to prevent further sickling. Sickling occurs in the presence of decreased oxygen tension and alterations in pH. The hard sickle-shaped cells catch on each other and can eventually occlude vessels; that decreases oxygenation of the area and increases the sickling process.
The nurse is assessing a child with ketoacidosis. The nurse should particulary determine if the client has:
Deep, rapid respirations. The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide.
The client with a peptic ulcer is prescribed antibiotics and bismuth salts. The nurse explains that this combination of medications will:
Eradicate the Helicobacter pylori bacteria. H. pylori is present in 70% of patients with peptic ulcers. Bacteriostatic or bacteriocidal antibiotics are given to eradicate the bacteria from the gastric mucosa. Bismuth salts suppress the H. pylori bacteria and help to heal the mucosa. Although sometimes indicated, surgery for peptic ulcer is much less common now that the role of H. pylori in the development of gastric ulcers is understood.
The parent of a 4-year-old expresses concern that the child may be hyperactive. The parent describes the child as always in motion, constantly dropping and spilling things. Which action would be appropriate at this time?
Explain that this is not unusual behavior.
A 3-year-old boy has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process?
Pneumonia
For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acid--base imbalances?
Metabolic alkalosis. Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid--base bicarbonate increases, and the pH becomes more alkaline. Respiratory alkalosis is caused by conditions such as hyperventilation that result in loss of partial pressure of arterial carbon dioxide (PaCO2). Respiratory acidosis is caused by conditions such as inadequate ventilation that result in excessive retention of PaCO2. Metabolic acidosis results from the loss of large amounts of bicarbonate such as with severe diarrhea.
A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the physician immediately?
Moderate intercostal retractions. Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician.
The father of a preschool-age child with a tentative diagnosis of juvenile idiopathic arthritis (JIA) asks about a test to definitively diagnose JIA. The nurse's response is based on knowledge of what information?
No specific laboratory test is diagnostic. Explanation: The nurse's response to the father is based on the knowledge that there is no definitive test for JIA. The latex fixation test, which is commonly used to diagnose arthritis in adults, is negative in 90% of children.
A 3-year-old client is admitted to the pediatric unit with pneumonia. The child has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the child hasn't been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should the nurse include in the care plan? Select all that apply.
Perform chest physiotherapy as ordered. • Encourage coughing and deep breathing. • Perform postural drainage. • Maintain humidification with a cool mist humidifier. Chest physiotherapy and postural drainage work together to break up congestion and then drain secretions. Coughing and deep breathing are also effective to remove congestion.
Parents of a 5-year-old call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What should the nurse advise them to do?
Schedule an immediate appointment with their health care provider.
When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?
The client passes flatus. Passing flatus indicates the return of peristalsis, as does active bowel sounds. Hunger is not the best indicator of peristaltic return.
A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention?
The pedal pulse of the right leg isn't detectable.
The mother asks the nurse why peanuts are one of the worst things a child can aspirate. Which of the following should the nurse include in the explanation as the main reason for the problem associated with aspirating peanuts?
They swell when wet.
Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness?
Tragus, mastoid process, and helix
The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter's condition. The nurse should reply:
What is it that concerns you about having the school know about your daughter's condition?" Explanation: The nurse's first response should be to obtain more information about the mother's concerns. It is true that the child may have a diabetic reaction anywhere at school, and it is advisable that her teacher, classmates, and other adults know about her diabetes in order to help her; however, it is ultimately the client and her parents who will make the decision about informing the school.
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principle should the nurse address first?
When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principle should the nurse address first?
A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client?
Within 2 weeks Bone marrow depression is most likely to occur 10 days after methotrexate is administered.
A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to:
a 9-year-old child receiving subcutaneous insulin for treatment of diabetes mellitus. The nurse-manager should assign the LPN to the child with diabetes mellitus. Because he's receiving subcutaneous insulin rather than I.V. insulin.
A child, age 5, has acute lymphocytic leukemia (ALL) and is receiving induction chemotherapy consisting of vincristine, asparaginase, and prednisone. When teaching the parents about the adverse effects of this regimen, the nurse should stress the importance of promptly reporting:
blindness.
A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has:
coarctation of the aorta.
When caring for a child who has been receiving long-term steroid therapy, the nurse should assess the child for:
development of truncal obesity. One of the side effects of steroid therapy is fat deposition on the trunk and face, producing classic Cushingoid signs. Therefore, the nurse should expect to find truncal obesity. Steroids also can cause altered moods or mood swings. Typically, long-term steroid use results in weight gain. Steroids may inhibit the action of growth hormone. Therefore, a growth spurt is not likely.
At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should:
evaluate the tube for patency. The t-tube should drain approximately 300 to 500 mL in the first 24 hours, and after 3 to 4 days the amount should decrease to less than 200 mL in 24 hours. With the sudden decrease in drainage at 0800, the nurse should immediately assess the tube for obstruction of flow that can be caused by kinks in the tube or the client lying on the tube. Drainage color must also be assessed for signs of bleeding. The tube should not be irrigated or clamped without a prescription.
A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?
increased serum amylase and lipase levels Serum amylase and lipase are increased in pancreatitis, as is urine amylase. Other abnormal laboratory values include decreased calcium level and increased glucose and lipid levels.
A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply.
respiratory distress • fluid and electrolyte imbalance Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels.
The nurse teaches the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole for a urinary tract infection about appropriate care measures. Which of the following should be included in the teaching plan? Select all that apply.
• Using a sunscreen. • Keeping medication out of the sunlight. • Keeping the child well hydrated.
