a home care nurse instructs the mother of a 5 year old child with lactose intolerance about dietary measures for her child the nurse should tell the m
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NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A home care nurse instructs the mother of a 5-year-old child with lactose intolerance about dietary measures for her child. The nurse should tell the mother that it is necessary to provide which dietary supplement in the child's diet?

Correct answer: D

Rationale: In lactose intolerance, the inability to digest lactose, the sugar in dairy products, can lead to calcium deficiency if dairy products are removed from the diet. Calcium is crucial for bone health and other bodily functions, so alternative calcium sources like fortified non-dairy milks or leafy greens must be included to prevent deficiency. While fats and proteins are important nutrients, they are not typically deficient in lactose intolerance. Zinc, although an essential mineral, is not the primary concern in this case.

2. A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?

Correct answer: D

Rationale: The correct answer is that red blood cells have a lifespan of 120 days in the body. This allows for efficient oxygen transport throughout the circulatory system. Choices A, B, and C are incorrect because the lifespan of red blood cells is actually 120 days. Understanding the lifespan of red blood cells is crucial in assessing various conditions related to blood cell production and turnover.

3. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?

Correct answer: D

Rationale: Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.

4. The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

Correct answer: A

Rationale: The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.

5. The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?

Correct answer: B

Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. The nurse counted eight respirations over 30 seconds, so doubling this count gives a respiratory rate of 16 breaths per minute. This calculation is based on the assumption that the client's breathing pattern remained relatively stable during the two 30-second intervals. Options A, C, and D are incorrect because they do not reflect the accurate count obtained without interruptions. Choice B (16) is the correct answer as it reflects the uninterrupted count of respirations by the nurse.

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