the nurse is caring for an infant with a diagnosis of bladder exstrophy to protect the exposed bladder tissue the nurse should plan which intervention
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Exam Review Answers

1. The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?

Correct answer: C

Rationale: Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.

2. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

Correct answer: C

Rationale: Vesicles are fluid-filled blisters. In the context of the upper torso, the presentation of vesicles suggests a second-degree sunburn. Sunburn can cause blistering, leading to the formation of vesicles. Choice A, 'Knife fight,' does not align with the presentation of vesicles on the upper torso due to trauma. Choice B, 'Auto accident,' is more likely to cause abrasions or bruises rather than vesicles. Choice D, 'Fungal infection,' typically presents with other symptoms such as redness, itching, or scaling, but not vesicles on the upper torso.

3. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?

Correct answer: B

Rationale: The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.

4. You are responsible for reviewing the nursing unit's refrigerator. Which of the following drugs, if found inside the fridge, should be removed?

Correct answer: A

Rationale:

5. For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

Correct answer: A

Rationale: Institute seizure precautions. The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications, and anticipatory preparation such as seizure precautions is needed. Weighing the child twice per shift may be necessary for monitoring fluid balance but is not specifically related to the complications of AGN. Encouraging the child to eat protein-rich foods is important for overall nutrition but does not directly address the potential complications of AGN. Relieving boredom through physical activity is beneficial for overall well-being but is not the priority in this situation where seizure precautions are essential.

Similar Questions

The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses