NCLEX-RN
NCLEX RN Exam Review Answers
1. The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?
- A. Caution should be used when straddling my infant on a hip.
- B. Vital signs should be taken daily to check for bladder infection.
- C. Catheterization will be necessary when my infant does not void.
- D. Circumcision has been delayed to save tissue for surgical repair.
Correct answer: D
Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.
2. Which fact about diabetes is true?
- A. Only children get type 1 diabetes.
- B. Only adults get type 2 diabetes.
- C. Children and adults can have type 1 diabetes.
- D. Both A and B
Correct answer: C
Rationale: The correct answer is that children and adults can have type 1 diabetes. Although type 1 diabetes is sometimes known as 'childhood diabetes,' it can affect individuals of any age. Type 1 diabetes is not limited to children. While type 2 diabetes is often associated with adults, children can also develop it, especially due to factors like obesity. Choices A and B are incorrect because diabetes is not exclusive to either children or adults; both types of diabetes can affect individuals across different age groups.
3. When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?
- A. Hematuria
- B. Proteinuria
- C. Bacteriuria
- D. Glucosuria
Correct answer: C
Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.
4. A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?
- A. I can clean the skin around the ostomy site with soap and water when I change the bag.
- B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
- C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
- D. I should change the bag when it is one-third to one-fourth full.
Correct answer: C
Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.
5. In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?
- A. Assessment
- B. Analysis
- C. Planning
- D. Implementation
Correct answer: D
Rationale: The correct answer is 'Implementation.' In the nursing process, implementation involves carrying out the planned interventions to meet the patient's goals. Encouraging the patient to attend a psychoeducational group daily is an intervention aimed at building social skills. Assessment (choice A) is the phase where data about the patient's condition is collected. Analysis (choice B) involves interpreting the gathered data. Planning (choice C) is where the nurse decides on the interventions to address the patient's needs. Therefore, in this scenario, recording the item 'Encourage patient to attend one psychoeducational group daily' would be part of the implementation phase.
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