NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. Parents of a 6-month-old breastfed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
- A. Cereal
- B. Eggs
- C. Meat
- D. Juice
Correct answer: A
Rationale: The correct answer is 'Cereal.' The guidelines of the American Academy of Pediatrics recommend introducing one new food at a time, starting with strained cereal. Cereal is often recommended as a first solid food for infants due to its soft texture and iron-fortified properties, which are important for the baby's development. Eggs and meat are common allergenic foods and are usually introduced later. Juice is not recommended for infants under 1 year old due to its high sugar content and lack of nutritional value compared to whole fruits.
2. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
3. Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?
- A. Elevate the lower extremities to 45 degrees to promote venous return
- B. Place Mr. C in the Trendelenburg position
- C. Administer total parenteral nutrition
- D. Monitor urine output
Correct answer: D
Rationale: In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.
4. Which entry in the medical record best meets the requirement for problem-oriented charting?
- A. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."?
- B. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."?
- C. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."?
- D. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"?
Correct answer: B
Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.
5. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?
- A. Polyuria
- B. Weight gain
- C. Hypotension
- D. Grossly bloody urine
Correct answer: B
Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.
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