The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

Questions 80

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Simulated Exam Test Bank Questions

Question 1 of 4

The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

Correct Answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.

Question 2 of 4

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?

Correct Answer: A

Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.

Question 3 of 4

A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

Correct Answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.

Question 4 of 4

While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

Correct Answer: B

Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.

Access More Questions!

NCLEX RN Basic


$89/ 30 days

NCLEX RN Premium


$150/ 90 days

Similar Questions