NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.
Question 2 of 5
The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.
Question 3 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 4 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.
Question 5 of 5
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
Correct Answer: D
Rationale: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.