NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?
Correct Answer: A
Rationale: The nurse avoids injecting any substance into a client's NGT before verifying tube placement because NGTs can migrate out of the stomach. If the NGT is not in the correct location, subsequent injections or feedings through the tube can lead to serious complications such as aspiration. None of the remaining options are priorities before administering an enteral feeding.
Question 2 of 5
The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?
Correct Answer: C
Rationale: After pyloromyotomy, the head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Based on this information, the remaining options are incorrect positions after this type of surgery. The surgeon's prescriptions for positioning should always be followed.
Question 3 of 5
A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?
Correct Answer: C
Rationale: The FHR should be between 120 and 160 beats/min. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the primary health care provider. The FHR would be documented, but option 3 is the appropriate action. The nurse would not tell the client that the FHR is fast at this point in time. Option 4 is an inappropriate action.
Question 4 of 5
The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
Correct Answer: C
Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.
Question 5 of 5
The nurse is caring for a hospitalized 14-year-old child who is placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?
Correct Answer: B
Rationale: An adolescent needs to identify with peers and has a strong need to belong to a group. The child should be allowed to wear his or her own clothes to feel a sense of belonging to the group. The adolescent likes to dress like the group and to wear similar hairstyles. Loud music may disturb others in the hospital. Because Crutchfield traction involves the use of skeletal pins, hair dye is not appropriate. The child's request for a darkened room is indicative of a possible problem with depression that may require further evaluation and intervention.