a 6 month old client is admitted with possible intussuception which question during the nursing history is least helpful in obtaining information rega
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NCLEX-PN

Nclex Practice Questions 2024

1. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

Correct answer: C

Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.

2. A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?

Correct answer: B

Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.

3. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

Correct answer: D

Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.

4. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:

Correct answer: D

Rationale: For a client with acute leukemia and a low white blood cell count, preventing exposure to food contaminants is crucial due to immune suppression. Providing foods in sealed single-serving packages helps reduce the risk of contamination. Choice B is incorrect as it introduces the potential of infection from visitors. Choice A, suggesting disposable utensils, is not as effective as sealed containers in preventing food contamination. Choice C, using alcohol for prepping IV sites, is less suitable due to its drying effect and potential for skin breakdown, making sealed packages a better option for food safety.

5. Which nurse should be assigned to care for the postpartal client with preeclampsia?

Correct answer: B

Rationale: The nurse with 3 years of experience in labor and delivery (answer B) should be assigned to care for the postpartal client with preeclampsia. This nurse has the most relevant experience and knowledge of possible complications associated with preeclampsia due to their background in labor and delivery. Assigning a nurse with only 2 weeks of experience on the postpartum unit (answer A) would not be suitable for handling the complexities of caring for a client with preeclampsia. Nurses with experience in surgery (answer C) or the neonatal intensive care unit (answer D) lack the specific expertise needed for managing a postpartal client with preeclampsia, making them unsuitable choices for this assignment.

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