NCLEX-RN
NCLEX RN Exam Review Answers
1. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
- A. The infant had doubled their birth weight at twelve months.
- B. The infant had tripled their birth weight at twelve months.
- C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
- D. The infant had grown � inch since last month.
Correct answer: A
Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown � inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.
2. Which of the following conditions may warrant a serum creatinine level?
- A. Rhabdomyolysis
- B. Digitalis toxicity
- C. Glomerulonephritis
- D. All answers are correct
Correct answer: D
Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.
3. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.
- A. nosocomial
- B. systemic
- C. resident flora
- D. resident aura
Correct answer: A
Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.
4. An assisted living facility is an example of which type of healthcare provider?
- A. Primary care
- B. Secondary care
- C. Tertiary care
- D. None of the above
Correct answer: C
Rationale: An assisted living facility is an example of a tertiary care provider. Tertiary care providers offer specialized services such as rehabilitation, long-term care, and management of complex medical conditions. These services are typically provided after primary and secondary care interventions. Choice A, primary care, focuses on preventive care and routine medical treatment for common illnesses, which is not the level of care provided by assisted living facilities. Choice B, secondary care, involves specialized medical services provided by medical specialists and hospitals for conditions that require a higher level of expertise than primary care, but it is not the level of care provided by assisted living facilities. Choice D, None of the above, is incorrect as assisted living facilities fall under the category of tertiary care providers.
5. The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?
- A. "You need to regain your strength before attempting such exertion."?
- B. "When you can climb 2 flights of stairs without problems, it is generally safe."?
- C. "Have a glass of wine to relax you, then you can try to have sex."?
- D. "If you can maintain an active walking program, you will have less risk."?
Correct answer: B
Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.
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