NCLEX-RN
Planning Questions
Question 1 of 5
Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy?
Correct Answer: A,B,C,E
Rationale: After tonsillectomy, clear, cool liquids are encouraged. Options 2 and 3 are important interventions after any type of surgery. Suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding.
Question 2 of 5
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
Correct Answer: C
Rationale: The formation of renal and urinary calculi is a complication of immobility. Limiting milk and milk products is the best measure to prevent the formation of calcium stones. A supine position increases urinary stasis; therefore, this position should be limited or avoided. Daily fluid intake should be 2000 mL or more per day. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting, polydipsia, polyuria, and lethargy.
Question 3 of 5
Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.
Question 4 of 5
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
Correct Answer: D
Rationale: Health promotion focuses on helping clients identify and examine dysfunctional thoughts, as well as identifying and examining the values and beliefs that maintain these thoughts. Providing a supportive environment is important, but it is not as primary as option 4 for this client. Examining intrapsychic conflicts and past issues is not directly related to the client's problem. Emphasizing social interaction is not appropriate at this time.
Question 5 of 5
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
Correct Answer: C
Rationale: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.