NCLEX RN Exam Review Answers - Nurselytic

Correct Answer: A

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age
The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight.
As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

Correct Answer: C

Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.

Correct Answer: D

Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments.
Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.

Correct Answer: A

Rationale: Collegiality is the action of forming relationships and supporting others through work experiences. In this scenario, the nurse being promoted as a mentor and preceptor exemplifies collegiality by fostering an encouraging educational relationship with the new nursing staff. The nurse demonstrates appropriate nursing care, teaches skills, and supports the professional growth of others.
Choice B, 'Competence,' refers to having the necessary skills and knowledge, but in this context, the focus is on the supportive and educational role of the nurse.
Choice C, 'Advocacy,' involves speaking up for patients' rights and needs, which is not directly demonstrated in the scenario.
Choice D, 'Integration,' does not directly relate to the situation described, where the emphasis is on mentoring and guiding new staff.

Correct Answer: B

Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function.

Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (
Choice
A) is an example of educative care, placing an allergy wristband (
Choice
C) is a safety measure, and contacting a client's family to update them on surgery (
Choice
D) is related to communication and support, not restorative care.