Fundamentals Of Nursing NCLEX Quiz 29

1. The nurse is finishing her shift on the pediatric unit. Because her shift is ending. which intervention takes top priority?

Changing the linens on the clients’ beds

Restocking the bedside supplies needed for a dressing change on the upcoming shift

Documenting the care provided during her shift

Emptying the trash cans in the assigned client room

Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. The other three options would be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take priority over documentation.

Explanation

Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. The other three options would be appreciated by the nurses on the oncoming shift but aren’t mandatory and don’t take priority over documentation.

2. David. age 15 months. is recovering from surgery to remove Wilms' tumor. Which findings best indicates that the child is free from pain?

Decreased appetite

Increased heart rate

Decreased urine output

Increased interest in play

One of the most valuable clues to pain is a behavior change: A child whose pain-free likes to play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased urine output may signify dehydration.

Explanation

One of the most valuable clues to pain is a behavior change: A child whose pain-free likes to play. A child in pain is less likely to consume food or fluids. An increased heart rate may indicate increased pain; decreased urine output may signify dehydration.

3. When planning care for a 8-year-old boy with Down syndrome. the nurse should:

Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age

Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays

Assess the child’s current developmental level and plan care accordingly

Direct all teaching to the parents because the child can’t understand

Nursing care plan should be planned according to the developmental age of a child with Down syndrome. not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged. each child should be individually assessed. A child with Down syndrome is capable of learning. especially a child with mild limitations.

Explanation

Nursing care plan should be planned according to the developmental age of a child with Down syndrome. not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged. each child should be individually assessed. A child with Down syndrome is capable of learning. especially a child with mild limitations.

4. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

Instituting droplet precautions

Administering acetaminophen (Tylenol)

Obtaining history information from the parents

Orienting the parents to the pediatric unit

Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.

Explanation

Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.

5. An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written. informed consent for the procedure?

The foster mother

The social worker who placed the infant in the foster home

The registered nurse caring for the infant

The nurse-manager

When children are minors and aren’t emancipated. their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore. the foster mother is authorized to give consent for the blood transfusion. The social workers. the nurse. and the nurse-manager have no legal rights to give consent in this scenario.

Explanation

When children are minors and aren’t emancipated. their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore. the foster mother is authorized to give consent for the blood transfusion. The social workers. the nurse. and the nurse-manager have no legal rights to give consent in this scenario.

6. Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should take priority?

Prevent accidents

Keeping a night light on to allay fears

Explaining normalcy of fears about body integrity

Encouraging the child to dress without help

Accidents are the major cause of death and disability during the school-age years. Therefore. accident prevention should take priority when teaching parents of school-age children. Preschool (not school-age) children are afraid of the dark. have fears concerning body integrity. and should be encouraged to dress without help (with the exception of tying shoes).

Explanation

Accidents are the major cause of death and disability during the school-age years. Therefore. accident prevention should take priority when teaching parents of school-age children. Preschool (not school-age) children are afraid of the dark. have fears concerning body integrity. and should be encouraged to dress without help (with the exception of tying shoes).

7. Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is:

Developmental readiness of the child

Consistency in approach

The mother’s positive attitude

Developmental level of the child’s peers

If the child isn’t developmentally ready. child and parent will become frustrated. Consistency is important once toilet training has already started. The mother’s positive attitude is important when the child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.

Explanation

If the child isn’t developmentally ready. child and parent will become frustrated. Consistency is important once toilet training has already started. The mother’s positive attitude is important when the child is ready. Developmental levels of children are individualized and comparison to peers isn’t useful.

8. Nurse Roy is administering total parental nutrition (TPN) through a peripheral I.V. line to a school-age child. What's the smallest amount of glucose that's considered safe and not caustic to small veins. while also providing adequate TPN?

5% glucose

10% glucose

15% glucose

17% glucose

The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement. although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access.

Explanation

The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. Five percent glucose isn’t sufficient nutritional replacement. although it’s sake for peripheral veins. Any amount above 10% must be administered via central venous access.

9. Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child. age 4. the nurse should:

Compress the sternum with both hands at a depth of 1½ to 2” (4 to 5 cm)

Deliver 12 breaths/minute

Perform only two-person CPR

Use the heel of one hand for sternal compressions

The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child. two-person rescue may be inappropriate. For a child. the nurse should deliver 20 breaths/minute instead of 12.

Explanation

The nurse should use the heel of one hand and compress 1” to 1½ “. The nurse should use the heels of both hands clasped together and compress the sternum 1½ “to 2” for an adult. For a small child. two-person rescue may be inappropriate. For a child. the nurse should deliver 20 breaths/minute instead of 12.

10. A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client's chemotherapy regimen is to:

Prevent metabolic breakdown of xanthine to uric acid

Prevent uric acid from precipitating in the ureters

Enhance the production of uric acid to ensure adequate excretion of urine

Ensure that the chemotherapy doesn’t adversely affect the bone marrow

The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.

Explanation

The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. Allopurinol doesn’t act in the manner described in the other options.