NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?
Correct Answer: C
Rationale: Cerebral palsy is a chronic disability that is characterized by difficulty with controlling the muscles because of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infections. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
Question 2 of 5
The nurse preparing to admit a 7-month-old infant with febrile seizures should anticipate the need for which equipment when planning care for this infant?
Correct Answer: C
Rationale: Suctioning may be required during a seizure to remove secretions that obstruct the airway. An airway should also be readily available. During a seizure, the infant should be placed in a side-lying position, but should not be restrained. It is not necessary to place a code cart at the bedside, but a cart should be readily available on the nursing unit. A padded tongue blade should never be used; in fact, nothing should be placed in the mouth during a seizure.
Question 3 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.
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 planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.