NCLEX-RN
Planning Questions
Extract:
Question 1 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 2 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 3 of 5
A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?
Correct Answer: D
Rationale: Cerebral edema is a progressive part of the disease process of Reye's syndrome. A priority component of care for a child with Reye's syndrome is maintaining effective cerebral perfusion and controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue, as well as neuron responses. Hearing loss does not occur in clients with this disorder. Although monitoring I&O may be a component of the plan, it is not the priority nursing action. Changing the body position every 2 hours would not affect the cerebral edema and intracranial pressure directly. The child should be in a head-elevated position to decrease the progression of cerebral edema and promote the drainage of cerebrospinal fluid.
Question 4 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 5 of 5
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.