NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
The school nurse is preparing to perform health screening for scoliosis on children aged 9 through 14. Which instruction should the nurse plan to provide to the children?
Correct Answer: D
Rationale:
To perform this screening test, the child should be asked to disrobe or wear underpants only so that the chest, back, and hips can be clearly seen. The child is asked to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. The nurse assesses the child's posture, spinal column, shoulder height, and leg lengths. Lying down positions and walking forward and backward are incorrect assessment techniques.
Question 2 of 5
The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
Question 3 of 5
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
Correct Answer: C
Rationale: The formation of renal and urinary calculi is a complication of immobility. Limiting milk and milk products is the best measure to prevent the formation of calcium stones. A supine position increases urinary stasis; therefore, this position should be limited or avoided. Daily fluid intake should be 2000 mL or more per day. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting, polydipsia, polyuria, and lethargy.
Question 4 of 5
The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?
Correct Answer: D
Rationale: Sterile technique is vital during dressing changes of a central venous catheter (CV
C). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.
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.