Fundamentals Of Nursing NCLEX Quiz 30

1. A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the result be evaluated?

Immediately

Within 24 hours

In 48 to 72 hours

After 5 days

Tuberculin skin tests of delayed hypersensitivity. If the test results are positive. a reaction should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible.

Explanation

Tuberculin skin tests of delayed hypersensitivity. If the test results are positive. a reaction should appear in 48 to 72 hours. Immediately after the test and within 24 hours are both too soon to observe a reaction. Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible.

2. A child has third-degree burns of the hands. face. and chest. Which nursing diagnosis takes priority?

Ineffective airway clearance related to edema

Disturbed body image related to physical appearance

Impaired urinary elimination related to fluid loss

Risk for infection related to epidermal disruption

Initially. when a preschool client is admitted to the hospital for burns. the primary focus is on assessing and managing an effective airway. Body image disturbance. impaired urinary elimination. and infection are all integral parts of burn management but aren’t the first priority.

Explanation

Initially. when a preschool client is admitted to the hospital for burns. the primary focus is on assessing and managing an effective airway. Body image disturbance. impaired urinary elimination. and infection are all integral parts of burn management but aren’t the first priority.

3. Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?

Measuring head circumference

Obtaining skull X-ray

Performing a lumbar puncture

Magnetic resonance imaging (MRI)

Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus. and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t appropriate.

Explanation

Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus. and is a key part of routine infant screening. Skull X-rays and MRI may be used to confirm the diagnosis. A lumbar puncture isn’t appropriate.

4. A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?

Worsening dyspnea

Gastric distension

Nausea and vomiting

Temperature of 102°F (38.9° C)

Dyspnea and other signs of respiratory distress signify fluid volume excess (overload). which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit.

Explanation

Dyspnea and other signs of respiratory distress signify fluid volume excess (overload). which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention may suggest excessive oral fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit.

5. Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison. what should the parents do first?

Administer ipecac syrup

Call an ambulance immediately

Call the poison control center

Punish the child for being bad

Before interviewing in any way. the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe.

Explanation

Before interviewing in any way. the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe.

6. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission. which personal protective should the nurse wear?

Gloves

Gown and gloves

Gown. gloves. and mask

Gown. gloves. mask. and eye goggles or eye shield

The transmission of SARS isn’t fully understood. Therefore. all modes of transmission must be considered possible. including airborne. droplet. and direct contact with the virus. For protection from contracting SARS. any health care worker providing care for a client with SARS should wear a gown. gloves. mask. and eye goggles or an eye shield.

Explanation

The transmission of SARS isn’t fully understood. Therefore. all modes of transmission must be considered possible. including airborne. droplet. and direct contact with the virus. For protection from contracting SARS. any health care worker providing care for a client with SARS should wear a gown. gloves. mask. and eye goggles or an eye shield.

7. An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?

Apply cool air under the cast with a blow-dryer

Use sterile applicators to scratch the itch

Apply cool water under the cast

Apply hydrocortisone cream under the cast using sterile applicator.

Itching underneath a cast can be relieved by directing blow-dryer. set. on the cool setting. toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore. the client should be cautioned not to put any object down the cast in an attempt to scratch.

Explanation

Itching underneath a cast can be relieved by directing blow-dryer. set. on the cool setting. toward the itchy area. Skin breakdown can occur if anything is placed under the cast. Therefore. the client should be cautioned not to put any object down the cast in an attempt to scratch.

8. Gracie. the mother of a 3-month-old infant calls the clinic and states that her child has a diaper rash. What should the nurse advice?

“Switch to cloth diapers until the rash is gone”

“Use baby wipes with each diaper change.”

“Leave the diaper off while the infant sleeps.”

“Offer extra fluids to the infant until the rash improves.”

Leaving the diaper off while the infant sleeps helps to promote air circulation to the area. improving the condition. Switching to cloth diapers isn’t necessary; in fact. that may make the rash worse. Baby wipes contain alcohol. which may worsen the condition. Extra fluids won’t make the rash better.

Explanation

Leaving the diaper off while the infant sleeps helps to promote air circulation to the area. improving the condition. Switching to cloth diapers isn’t necessary; in fact. that may make the rash worse. Baby wipes contain alcohol. which may worsen the condition. Extra fluids won’t make the rash better.

9. Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?

Oxygen saturation of 95%

Mild work of breathing

Absence of intercostals or substernal retractions

History of steroid-dependent asthma

A history of steroid-dependent asthma. a contributing factor to this client’s high-risk status. requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. An oxygen saturation of 95%. mild work of breathing. and absence of intercostals or substernal retractions are all normal findings.

Explanation

A history of steroid-dependent asthma. a contributing factor to this client’s high-risk status. requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. An oxygen saturation of 95%. mild work of breathing. and absence of intercostals or substernal retractions are all normal findings.

10. Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant's diet?

Iron-rich formula and baby food

Whole milk and baby food

Skim milk and baby food

Iron-rich formula only

The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t recommend whole milk until age 12 months. and skim milk until after age 2 years.

Explanation

The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. The Academy doesn’t recommend whole milk until age 12 months. and skim milk until after age 2 years.