NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
Correct Answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect.
Therefore, the other options are appropriate for the care of a child with hepatitis.
Question 2 of 5
A patient presents to the office with a pencil that has completely penetrated the palm of her hand. Which of the following treatments would be BEST in this situation?
Correct Answer: C
Rationale: Penetrating wounds that leave an object behind may have damaged important blood vessels. Removing the object may lead to significant bleeding. The correct approach is to gently wrap the wound with the object in place to help control bleeding and prevent further injury. The patient should be taken promptly to the nearest emergency room where healthcare professionals can safely and appropriately remove the object and provide necessary treatment.
Choice A is incorrect because removing the pencil without proper medical evaluation can worsen the injury.
Choice B is incorrect because pulling out the object can cause additional damage and bleeding.
Choice D is incorrect because giving aspirin without knowing the extent of the injury and causing potential drug interactions can be harmful.
Question 3 of 5
Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
Correct Answer: D
Rationale: Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.
Question 4 of 5
A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
Correct Answer: D
Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action.
Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.
Question 5 of 5
The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Correct Answer: D
Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.