NCLEX-RN
Planning Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
Correct Answer: B
Rationale: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.
Question 3 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 4 of 5
The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?
Correct Answer: D
Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure as a result of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring. Although some of the items in the remaining options may be kept at the bedside (e.g., pulse oximeter, blood pressure cuff, flashlight), they are not necessarily needed for emergency use in this situation.
Question 5 of 5
The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?
Correct Answer: C
Rationale: For the infant with clubfoot, casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment, or surgery can be performed. Surgery is usually delayed until the child is 4 to 12 months old. Options 1 and 4 are inaccurate. Option 2 does not specifically address the subject of the question.