NCLEX-RN
Planning Questions
Extract:
Question 1 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 2 of 5
The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?
Correct Answer: A
Rationale: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses.
Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.
Question 3 of 5
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.
Question 4 of 5
A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
Correct Answer: B
Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.
Question 5 of 5
Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.