NCLEX RN Practice Questions Exam Cram - Nurselytic

Correct Answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option
B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option
C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option
D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

Correct Answer: C

Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (
Choice
A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (
Choice
B) may reinforce negative behavior. Asserting authority through limit setting (
Choice
D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.

Correct Answer: B

Rationale: When a newborn is placed in a warming isolette due to difficulty maintaining temperature, the priority action is to continuously monitor the neonate's temperature to prevent overheating. Using heat lamps is unsafe as their temperature cannot be regulated, potentially causing harm. Warming medications and fluids before administration is not necessary in this situation. While touching the neonate with cold hands may startle them, it does not pose a safety risk compared to monitoring and controlling the temperature.

Correct Answer: A

Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.

Correct Answer: D

Rationale: Acute glomerulonephritis (AGN) is generally considered an immune-complex disease in response to a previous B-hemolytic streptococcal infection, typically occurring 4 to 6 weeks prior. It is not an infectious disease but a noninfectious renal condition.
Therefore, the parent's belief that the child 'caught' the disease is inaccurate.
Choice A is incorrect because AGN is not a direct streptococcal infection involving the kidney tubules but an immune response to a prior streptococcal infection.
Choice B is incorrect as AGN is not easily transmissible in schools and camps.
Choice C is incorrect as AGN is not usually associated with chronic respiratory infections but with a previous streptococcal infection.