NCLEX QUESTIONS UNIT 5
The nurse is monitoring for signs of dehydration and a one-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided
Rectal
The mother of a toddler with mom's ask the nurse what she needs to watch for in her child with this disease. The nurse base is the response on the understanding that mom says which type of a communicable disease
Respiratory disease caused by a virus involving the parotid gland
The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame Burns to the face and chest. The nurse notes a horse cough, and the client is expectorating sputum with black flex. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make
The burn has probably caused laryngeal edema, which has occluded the airway
The nurse is assisting with caring for a client who is receiving intravenous fluids and who has a stand for thickness burns injuries of the back and legs. The nurse understand that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation
Urine output
A nurse is told that an assigned client is suspected of having MRSA. Which precaution shut the nurse institute during the care of the client
Wearing a gown and gloves
A client return to the clinic for follow up treatment after skin biopsy of a suspicious lesion that was performed one week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understand that which characteristic describe the type of lesion
it is highly metastatic lesion is a nevus that has changed in color
The nurse reviews the home care instructions with a parent of a three-year-old with pertussis. Which statement by the parents indicates a need for further teaching
"I understand this whooping cough is viral and I have to let it run its course."
The nurse is reviewing the healthcare record of a client with a lesion that has been diagnosed as a basal cell carcinoma. Then I should expect which characteristic of this type of lesion to be documented in the clients records. Select all that apply
lesion has a waxy border and irregularly shaped lesion
The nurse reinforces home care instructions to the parent of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by the parent indicates I need for further teaching
"I need to provide a well-balanced, high fat diet to my child "
The nurse is reviewing instructions to a parent of a six-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 client arrives the emergency department afterburn injury that occurred in their home basement and in inhalation injury is suspected. What should the nurse anticipate as being prescribed for the client
100% oxygen via a tight fitting, non-breather face mask
an adult client was burned as a result of an explosion. The burn initially affected the clients entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential Burns to the lower half of both arms. The clients clothes caught on fire and the client ran which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, which is the extent of the clients burn injury
36% according to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head which equals 4.5% in the upper half of the posterior torso, which equals 9%
The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place a child during naps and sleep time
A side lying position
A client arrives the emergency department and has experience frostbite to the right hand. What should the nurse expect to find when inspecting the clients hand?
A white color of the skin which is insensitive to touch
The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign with staff member to the client with a diagnosis of herpes zoster
An unlicensed assistive personnel who has never had chickenpox
A six month old infant receives a DTaP Immunization at a well baby clinic. The parent returns home and called the clinic to report at the infant has developed swelling and redness at the side of injection. Which instruction by the nurse is appropriate
Apply an ice pack to the injection site
A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first
Check the circulation, airway, and breathing status of the child
The nurse is caring for a client with circumferential Burns of both legs. Which lake position is appropriate For this type of burn
Elevation above the level of the heart
The nurse reinforces instruction to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching.
I need to avoid sun exposure before 10 AM and after 4 PM
A child is diagnoses chickenpox. The nurse collect data regarding the child. Which finding is characteristic of chicken pox
Muscular rash on the trunk and scalp
A child is diagnosed with Scarlett fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever
Pastia's sign
A child with measles is admitted to the hospital. I'm preparing for the admission of the child, which precaution should the nurse implement. Select all that apply
contact airborne
which should be anticipated therapeutic outcome of an escharotomy procedure performed for circumferential arm burn
return of distal pulses