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NCLEX-RN Exam Questions - Part 107
1. A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother - s discharge teaching plan?
A) Keep the umbilical area moist with Vaseline until the stump falls off.
B) Keep the umbilical area covered at all times with the diaper.
C) Clean the umbilical cord with alcohol at each diaper change.
D) Clean the umbilical cord daily with soap and water during the bath.
2. Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
A) She uses the bulb syringe to help clear her baby - s nose when milk is regurgitated.
B) She places her infant on her right side after feeding her.
C) She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
D) She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
3. Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:
A) Immediately after birth, because the most accurate result is obtained at this time
B) After 2 - 3 days of milk ingestion
C) At 2 - 3 days of age regardless of amount of milk feedings
D) At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect
4. A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
A) Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
B) Giving clear liquids too soon
C) Allowing the child to come in contact with other children for 3 days
D) The possibility of pneumonia as a complication
5. A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client - s responses would indicate compliance during initial therapy?
A) Drinking large amounts of milk
B) Not bearing weight on affected extremity
C) Walking short distances 3 times/day
D) Putting self on weight reduction diet
A) Keep the umbilical area moist with Vaseline until the stump falls off.
B) Keep the umbilical area covered at all times with the diaper.
C) Clean the umbilical cord with alcohol at each diaper change.
D) Clean the umbilical cord daily with soap and water during the bath.
2. Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
A) She uses the bulb syringe to help clear her baby - s nose when milk is regurgitated.
B) She places her infant on her right side after feeding her.
C) She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
D) She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
3. Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:
A) Immediately after birth, because the most accurate result is obtained at this time
B) After 2 - 3 days of milk ingestion
C) At 2 - 3 days of age regardless of amount of milk feedings
D) At 1 month, because the biochemical buildup of phenylalanine takes 1 month to detect
4. A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
A) Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
B) Giving clear liquids too soon
C) Allowing the child to come in contact with other children for 3 days
D) The possibility of pneumonia as a complication
5. A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client - s responses would indicate compliance during initial therapy?
A) Drinking large amounts of milk
B) Not bearing weight on affected extremity
C) Walking short distances 3 times/day
D) Putting self on weight reduction diet
1. Right Answer: C
Explanation: (A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
2. Right Answer: C
Explanation: (A) This practice is the proper use of the bulb syringe to clear the infants airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
3. Right Answer: B
Explanation: (A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 23 full days of milk or formula feedings to preclude a false-negative reading. (C) At 23 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. (D) The biochemical buildup of serum phenylalanine is detectable after 23 days of milk or formula ingestion.
4. Right Answer: A
Explanation: (A) Aspirin should never be given to children with influenza because of the possibility of causing Reyes syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 13 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.
5. Right Answer: B
Explanation: (A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B)The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
Explanation: (A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
2. Right Answer: C
Explanation: (A) This practice is the proper use of the bulb syringe to clear the infants airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
3. Right Answer: B
Explanation: (A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 23 full days of milk or formula feedings to preclude a false-negative reading. (C) At 23 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. (D) The biochemical buildup of serum phenylalanine is detectable after 23 days of milk or formula ingestion.
4. Right Answer: A
Explanation: (A) Aspirin should never be given to children with influenza because of the possibility of causing Reyes syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 13 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral pneumonia can be a complication of influenza, this would not be an initial priority.
5. Right Answer: B
Explanation: (A) This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. (B)The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. (C) In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. (D) Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
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