NCLEX Practice Exam 23 (10 Questions)

1. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops. the nurse should recognize that it is essential to consider which of the following?

The eye should be cleansed with warm water. removing any exudate. before instilling the eyedrops.

The child should be allowed to instill his own eye drops.

The mother should be allowed to instill the eyedrops.

If the eye is clear from any redness or edema. the eyedrops should be held.

Before instilling eye drops. the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops. so answer B is incorrect. Although the mother of the child can instill the eyedrops. the area must be cleansed before administration. making answer C incorrect. Although the eye might appear to be clear. the nurse should instill the eyedrops. as ordered. so answer D is incorrect.

Explanation

Before instilling eye drops. the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops. so answer B is incorrect. Although the mother of the child can instill the eyedrops. the area must be cleansed before administration. making answer C incorrect. Although the eye might appear to be clear. the nurse should instill the eyedrops. as ordered. so answer D is incorrect.

2. The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway. which of the following should the nurse have available?

Intravenous access supplies

A tracheostomy set

Intravenous fluid administration pump

Supplemental oxygen

For a child with epiglottitis and the possibility of complete obstruction of the airway. emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies. fluid. and oxygen will not treat an obstruction; therefore. answers A. C. and D are incorrect.

Explanation

For a child with epiglottitis and the possibility of complete obstruction of the airway. emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies. fluid. and oxygen will not treat an obstruction; therefore. answers A. C. and D are incorrect.

3. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

Ask the parent/guardian to leave the room when assessments are being performed.

Ask the parent/guardian to room-in with the child.

If the child is screaming. tell him this is inappropriate behavior.

The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore. answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.

Explanation

The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore. answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.

4. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

High fever

Nonproductive cough

Rhinitis

Vomiting and diarrhea

If the child has bacterial pneumonia. a high fever is usually present. Bacterial pneumonia usually presents with a productive cough. not a nonproductive cough. making answer B incorrect. Rhinitis is often seen with viral pneumonia. and vomiting and diarrhea are usually not seen with pneumonia. so answers C and D are incorrect.

Explanation

If the child has bacterial pneumonia. a high fever is usually present. Bacterial pneumonia usually presents with a productive cough. not a nonproductive cough. making answer B incorrect. Rhinitis is often seen with viral pneumonia. and vomiting and diarrhea are usually not seen with pneumonia. so answers C and D are incorrect.

5. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds. the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

Notify the physician

Recheck the O2 saturation level in 15 minutes

Apply oxygen by mask

Assess the pulse

Remember the ABCs (airway. breathing. circulation) when answering this question. Before notifying the physician or assessing the pulse. oxygen should be applied to increase the oxygen saturation. so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%. making answer B incorrect.

Explanation

Remember the ABCs (airway. breathing. circulation) when answering this question. Before notifying the physician or assessing the pulse. oxygen should be applied to increase the oxygen saturation. so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%. making answer B incorrect.

6. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

Body image disturbance

Impaired verbal communication

Risk for aspiration

Pain

Always remember your ABCs (airway. breathing. circulation) when selecting an answer. Although answers B and D might be appropriate for this child. answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.

Explanation

Always remember your ABCs (airway. breathing. circulation) when selecting an answer. Although answers B and D might be appropriate for this child. answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.

7. A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

Bradycardia

Decreased appetite

Exophthalmos

Weight gain

Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia. increased appetite. and weight loss; therefore. answers A. B. and D are incorrect.

Explanation

Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia. increased appetite. and weight loss; therefore. answers A. B. and D are incorrect.

8. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements. if made by the mother. would require a need for further instruction?

“It is okay to give my child white grape juice for breakfast.”

“My child can have a grilled cheese sandwich for lunch.”

“We are going on a camping trip this weekend. and I have bought hot dogs to grill for his lunch.”

“For a snack. my child can have ice cream.”

Remember the ABCs (airway. breathing. circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A. B. and C are incorrect because white grape juice. a grilled cheese sandwich. and ice cream do not pose a risk of aspiration for a child.

Explanation

Remember the ABCs (airway. breathing. circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A. B. and C are incorrect because white grape juice. a grilled cheese sandwich. and ice cream do not pose a risk of aspiration for a child.

9. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods. if selected by the mother. would indicate her understanding of the dietary instructions?

Ham sandwich on whole-wheat toast

Spaghetti and meatballs

Hamburger with ketchup

Cheese omelet

The child with celiac disease should be on a gluten-free diet. Answers A. B. and C all contain gluten. while answer D gives the only choice of foods that does not contain gluten.

Explanation

The child with celiac disease should be on a gluten-free diet. Answers A. B. and C all contain gluten. while answer D gives the only choice of foods that does not contain gluten.

10. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?

Remove the mold and clean every week.

Store the hearing aid in a warm place.

Clean the lint from the hearing aid with a toothpick.

Change the batteries weekly.

The hearing aid should be stored in a warm. dry place. It should be cleaned daily but should not be moldy. so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide. making answer C incorrect. Changing the batteries weekly. as in answer D. is not necessary.

Explanation

The hearing aid should be stored in a warm. dry place. It should be cleaned daily but should not be moldy. so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide. making answer C incorrect. Changing the batteries weekly. as in answer D. is not necessary.