ATI RN
Pediatric NCLEX Questions Questions
Question 1 of 5
Which of the ff is a nursing intervention when assessing clients with hypertension?
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.
Question 2 of 5
The nurse is aware that a common physiologic adaptation of children with tetralogy of Fallot is:
Correct Answer: A
Rationale: Clubbing of fingers is a common physiologic adaptation seen in children with tetralogy of Fallot. Clubbing is the result of chronic hypoxia and decreased oxygen levels in the blood. In children with tetralogy of Fallot, there is a structural defect in the heart that leads to mixing of oxygenated and deoxygenated blood in the heart and decreased oxygenation of the blood circulating to the body. This chronic hypoxia can cause clubbing of the fingers, where the tips of the fingers appear enlarged and the nails are rounded. Therefore, clubbing of fingers is a key sign to monitor in children with tetralogy of Fallot.
Question 3 of 5
A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, "I refuse to take care of that dirty old man!" Which response by the nurse is best?
Correct Answer: B
Rationale: The best response by the nurse is to address the situation with understanding and empathy. Referring to the patient as a "dirty old man" is disrespectful and unprofessional. The nurse should acknowledge that the patient's behavior may be a result of the stroke affecting his inhibitions and offer a solution to find a male assistant to help him, recognizing the nursing assistant's discomfort while still providing care for the patient. It is important to prioritize the well-being and comfort of both the patient and the staff while maintaining professionalism and dignity in the care provided.
Question 4 of 5
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
Correct Answer: B
Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.
Question 5 of 5
Nursing intervention during the lumbar puncture procedure includes:
Correct Answer: C
Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.