NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Nursing care for the parents of a child with a congenital heart defect would include:
Correct Answer: B
Rationale: It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. Anger and resentment are normal feelings that must be dealt with appropriately. Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'
Question 2 of 5
Nursing care for the parents of a child with a congenital heart defect would include:
Correct Answer: B
Rationale: It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. Anger and resentment are normal feelings that must be dealt with appropriately. Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'
Question 3 of 5
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
Correct Answer: C
Rationale: Pericarditis can cause dyspnea but primarily causes chest pain. Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.
Question 4 of 5
A 48-hour-old male infant is ordered to have phototherapy. When his mother questions the nurse about its purpose, the nurse explains that phototherapy:
Correct Answer: C
Rationale: The instillation of erythromycin ophthalmic preparation, not phototherapy, prevents ophthalmia neonatorum. The administration of vitamin K (AquaMEPHYTON) assists the infant's clotting mechanism. Excessive bilirubin accumulates when the infant's liver cannot handle the increased load caused by the breakdown of red blood cells postnatally. This excessive bilirubin seeps out of the blood and into the tissues, staining them yellow. Phototherapy accelerates the removal of bilirubin from the skin by breaking it down into substances that can be excreted in stool or urine. Phototherapy decreases levels of unconjugated bilirubin, thereby preventing kernicterus.
Question 5 of 5
At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is:
Correct Answer: C
Rationale: Compounds in cigarettes and some illicit drugs cause maternal vasoconstriction and a subsequent reduction in O2 availability for the fetus, leading to intrauterine growth retardation. Alcohol consumption also decreases birth weight.