NCLEX-RN
NCLEX RN Health Promotion and Maintenance Practice Questions Questions
Extract:
Question 1 of 5
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.
Question 2 of 5
The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
Correct Answer: D
Rationale: The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent. Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The primary health care provider is notified of any odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth.
Question 3 of 5
The nurse is caring for a client diagnosed with end-stage renal disease. What areas are appropriate to assess to determine the client's wishes for end-of-life nursing care?
Correct Answer: A,B,E,F
Rationale: The nurse must assess the client's wishes for end-of-life nursing care because these can influence how the nurse sets priorities for planning and implementing care. End-of-life assessment related to nursing care should include the preferred place for death, client expectations for nursing care, the use of and the level of life-sustaining measures, and expectations regarding pain control and symptom management. Financial responsibilities for the funeral and where the funeral and burial will take place are issues that the client may want to discuss, but they are unrelated to nursing care.
Question 4 of 5
A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Tertiary prevention for repeated abuse focuses on overcoming physical and psychological effects and preventing future abuse. Appropriate interventions include reporting abuse to ensure safety, providing medications for pain and anxiety, exploring support options, and focusing on the woman's strengths to boost self-esteem. Avoiding discussions about pressing charges or past events is not helpful, as these help address implications and reduce guilt.
Question 5 of 5
The nurse caring for a child with congestive heart failure who will be discharged to home provides instructions to the parents regarding the administration of digoxin. Which statement by the mother indicates a need for further teaching?
Correct Answer: A
Rationale: Digoxin is a cardiac glycoside and should not be mixed with food or formula because this method may not ensure the child receives the entire dose if the food is not fully consumed. Checking the child's pulse, not repeating the dose after vomiting, and verifying the dose with another person are correct interventions to ensure safe administration.