ATI RN
NCLEX RN Pediatric Questions Questions
Question 1 of 5
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
Question 2 of 5
The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient's gastrointestinal tract is resuming normal function?
Correct Answer: B
Rationale: The presence of flatus (gas) is a positive sign that the patient's gastrointestinal tract is resuming normal function after a bowel resection surgery. Flatus production indicates that peristalsis and normal bowel motility are returning, allowing gas to move through the intestine. This is an important milestone in the postoperative recovery process, as it suggests the return of normal bowel function. The other options provided are not indicative of the return of normal gastrointestinal function.
Question 3 of 5
Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia?
Correct Answer: C
Rationale: Iron deficiency anemia is characterized by a decreased mean corpuscular volume (MCV) due to the microcytic red blood cells that result from inadequate iron availability for hemoglobin synthesis. This leads to smaller red blood cells, which are reflected in a decreased MCV. Iron deficiency anemia would not typically result in an increased hemoglobin or normal hematocrit since the lack of iron impairs the production of red blood cells. Additionally, the total iron-binding capacity (TIBC) would usually be increased in iron deficiency anemia as the body attempts to compensate for the decreased iron levels by increasing its ability to bind and transport iron. Therefore, the nurse would expect a decreased mean corpuscular volume (MCV) in a child with iron deficiency anemia.
Question 4 of 5
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?
Correct Answer: A
Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.
Question 5 of 5
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.