NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
The nurse determines that a tuberculin skin test is positive. Which diagnostic test should the nurse anticipate will be prescribed to confirm a diagnosis tuberculosis (TB)?
Correct Answer: B
Rationale: Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB.
Question 2 of 5
A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?
Correct Answer: C
Rationale: Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients; it can also lead to constipation.
Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the primary health care provider because this will cause an overload to the circulating blood volume and contribute to cardiac complications.
Question 3 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 4 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 5 of 5
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.