NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
Question 2 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 3 of 5
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy should the nurse plan to implement?
Correct Answer: D
Rationale: The client with diabetes insipidus excretes large amounts of extremely dilute urine. This usually occurs as a result of decreased synthesis or the release of antidiuretic hormone in clients with conditions such as head injury, surgery near the hypothalamus, or increased intracranial pressure. Corrective measures include allowing ample oral fluid intake, administering IV fluid as needed to replace sensible and insensible losses, and administering vasopressin. Diuretics are not administered. Sodium is not administered because the serum sodium level is usually high, as is the serum osmolality.
Question 4 of 5
A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). On the basis of the developmental stage of the infant, what intervention should the nurse include in the plan of care?
Correct Answer: D
Rationale: A 10-month-old infant is in the trust versus mistrust stage of psychosocial development, according to Erik Erikson, and the sensorimotor period of cognitive development, according to Jean Piaget. Hospitalization may have an adverse effect. A consistent routine accompanied by touching, rocking, and cuddling will help the child develop trust and provide sensory stimulation.
Total body restraint is unnecessary and an incorrect action.
Touching and holding the infant only when the parents visit will not provide adequate stimulation and interpersonal contact for the infant. RSV is not airborne (a mask is not required), and it is usually transmitted by the hands.
Question 5 of 5
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
Correct Answer: D
Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.