NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy?
Correct Answer: A,B,C,E
Rationale: After tonsillectomy, clear, cool liquids are encouraged. Options 2 and 3 are important interventions after any type of surgery. Suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding.
Question 2 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 3 of 5
A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?
Correct Answer: C
Rationale: Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients; it can also lead to constipation.
Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the primary health care provider because this will cause an overload to the circulating blood volume and contribute to cardiac complications.
Question 4 of 5
The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
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.