NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
Correct Answer: D
Rationale: Intussusception is a condition where a part of the bowel slides into the next section, causing an obstruction. The classic presentation includes severe abdominal pain that is crampy, intermittent, and may cause the child to draw knees to the chest. While vomiting can occur, it is not typically projectile in nature. A key hallmark of intussusception is the passage of bright red blood and mucus in the stools, often described as currant jelly-like. Watery diarrhea and ribbon-like stools are not typical signs of intussusception and should not be expected in a child with this condition.
Question 2 of 5
The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?
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.
Question 3 of 5
The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
Correct Answer: C
Rationale: In the immediate post-operative period following spinal fusion for scoliosis in a 13-year-old, it is important to maintain the patient in a flat position and perform logrolling as needed. This helps prevent injury to the surgical site and ensures proper spinal alignment. Raising the head of the bed at least 30 degrees is contraindicated as it can put strain on the surgical site. Encouraging ambulation within 24 hours may be appropriate in the recovery process but not in the immediate post-operative period. Encouraging leg contraction and relaxation after 48 hours may also be part of the rehabilitation process but is not a priority in the immediate post-operative period.
Question 4 of 5
A healthcare professional is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the healthcare professional to immediately discontinue this part of the assessment?
Correct Answer: B
Rationale: A pulsating mass on the upper middle abdomen is indicative of a life-threatening aortic aneurysm. Palpating or percussing such an area can potentially cause the aneurysm to rupture, leading to severe internal bleeding and endangering the patient's life.
Therefore, the healthcare professional should immediately discontinue the assessment to prevent any harm.\n
Choice A is incorrect because the patient expressing concerns about the procedure does not necessarily indicate a life-threatening condition.
Choice C describes symptoms that should be further investigated but do not pose an immediate threat during abdominal assessment.
Choice D, a prior endoscopic procedure, is not a contraindication for palpation or percussion of the abdomen unless there are specific complications or conditions related to the procedure that would require caution.
Question 5 of 5
When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?
Correct Answer: B
Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (
Choice
A) is not a typical symptom of pyloric stenosis. Increased urine output (
Choice
C) is not directly associated with this condition. Vomiting large amounts of bile (
Choice
D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.