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Home Test Prep NCLEX-RN

Test Prep NCLEX-RN Exam Practice Questions (P. 5)

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Question #41
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
  1. A
    Blood pressure
  2. B
    Serum potassium level
  3. C
    Urine output
  4. D
    Pulse rate

Correct Answer:
C
(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation.
(C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.

Question #42
Proper positioning for the child who is in Bryant’s traction is:
  1. A
    Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
  2. B
    Both legs extended, and the hips are not flexed
  3. C
    The affected leg extended with slight hip flexion
  4. D
    Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed

Correct Answer:
A
(A) The childs weight supplies the countertraction for Bryants traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle.
Both legs are suspended by skin traction. (B) The child in Bucks extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in "90–90" traction maintains both hips and knees at a
90-degree flexion angle and the back is flat on the bed.

Question #43
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
  1. A
    Bleeding, bruising, and hemorrhage
  2. B
    Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
  3. C
    Pain, pallor, pulselessness, paresthesia, and paralysis
  4. D
    Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus

Correct Answer:
C
(A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five "P’s": pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.

Question #44
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
  1. A
    Stephens-Johnson syndrome
  2. B
    Folate deficiency
  3. C
    Leukopenic aplastic anemia
  4. D
    Granulocytosis and nephrosis

Correct Answer:
A
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).

Question #45
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
  1. A
    Sustained temperature elevation over 103F is generally related to febrile seizures
  2. B
    Febrile seizures do not usually recur
  3. C
    There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
  4. D
    Febrile seizures are associated with diseases of the central nervous system

Correct Answer:
C
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.

Question #46
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
  1. A
    Anemia and vomiting
  2. B
    Polyuria and polydipsia
  3. C
    Irritability relieved by feeding formula
  4. D
    Hypothermia and azotemia

Correct Answer:
B
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.

Question #47
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
  1. A
    Weigh once a week and report to the physician any weight gain of10 lb.
  2. B
    Limit fluid intake to 500 mL/day.
  3. C
    Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration.
  4. D
    Hold the vial under warm water for 10–15 minutes and shake vigorously before drawing medication into the syringe.

Correct Answer:
D
(A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 1015 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.

Question #48
A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would note a characteristic rash:
  1. A
    That is covered with vesicular scabs all in the macular stage
  2. B
    That appears profusely on the trunk and sparsely on the extremities
  3. C
    That first appears on the neck and spreads downward
  4. D
    That appears especially on the cheeks, which gives a"slapped-cheek" appearance

Correct Answer:
B
(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities.
(C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a
"slapped-cheek" appearance is characteristic of roseola.

Question #49
Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:
  1. A
    Maintaining a high-humidified environment
  2. B
    Furry, soft stuffed animals for play
  3. C
    Showering 3–4 times a day
  4. D
    Wrapping hands in soft cotton gloves

Correct Answer:
D
(A) Maintaining a low-humidified environment. (B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. (C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. (D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching.

Question #50
The priority nursing goal when working with an autistic child is:
  1. A
    To establish trust with the child
  2. B
    To maintain communication with the family
  3. C
    To promote involvement in school activities
  4. D
    To maintain nutritional requirements

Correct Answer:
A
(A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child.

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