which would the nurse do when preparing to perform a physical examination on an infant

NCLEX-RN

NCLEX RN Exam Preview Answers

1. When preparing to perform a physical examination on an infant, what should the nurse do?

A. Have the parent remove all clothing except the diaper.
B. Instruct the parent not to feed the infant immediately before the examination.
C. Allow the infant to suck on a pacifier during abdominal auscultation.
D. Ensure the parent is present during the examination.

Correct answer: A

Rationale: For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.

2. Which of the following would be most important for the nurse to keep in mind regarding the use of side rails for a confused patient?

A. A person of small stature is at increased risk for injury from entrapment.
B. A history of a previous fall from a bed with raised side rails is significant.
C. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails.
D. Creative use of alternative measures indicates respect for the patient's dignity.

Correct answer: A

Rationale: When considering the use of side rails for a confused patient, it is crucial for the nurse to understand that individuals of small stature are at a higher risk for injury from entrapment. Studies have shown that people of small stature are more likely to slip through or between the side rails, making them vulnerable to harm. It is essential to prioritize patient safety and avoid potential risks associated with entrapment. Conversely, a history of previous falls from a bed with raised side rails is significant as it indicates a heightened risk for future serious incidents. The desire to prevent a patient from wandering alone does not justify the use of side rails; instead, alternative measures should be creatively employed to respect the patient's dignity and avoid more serious fall-related injuries.

3. The NFPA diamond has four colors. The blue diamond:

A. indicates hazards to health.
B. designates that it is safe to use water to put out this type of fire.
C. indicates that ice is necessary to treat an injury with this type of chemical.
D. indicates that the chemical may be incinerated upon disposal.

Correct answer: A

Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.

4. What does the medical term 'basophilia' refer to?

A. An attachment of the epithelial cells of the skin to a basement membrane
B. An overabundance of a particular white blood cell in the peripheral blood
C. An underrepresentation of basophils on a blood smear
D. None of the above

Correct answer: B

Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.

5. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

A. The nurse ties the restraints in a square knot to prevent the client from untying them
B. The restraints are attached to a movable portion of the bed
C. The padded side of the restraint is applied next to the skin of the wrist
D. The nurse assesses the client's distal circulation every 24 hours

Correct answer: C

Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.