|Exam Name||National Council Licensure Examination(NCLEX-RN)|
|Update Date||September 18,2023|
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A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby’s condition. The nurse knows that the pediatrician has discussed the baby’s condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?
A. Call the orthopedist and request that he come to see the baby now.
B. Question the mother and find out what the pediatrician has told her about the baby’scondition.
C. Tell the mother that this is not a serious condition.
D. Tell the mother that this condition has been successfully treated with exercises, casts,and/or braces.
A client states to his nurse that “I was told by the doctor not to take one of my drugsbecause it seems to have caused decreasing blood cells.” Based on this information, whichdrug might the nurse expect to be discontinued?
B. Timolol maleate (Blocadren)
C. Garamycin (Gentamicin)
D. Phenytoin (Dilantin)
A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:
B. Low-grade fever
A 19-month-old child is admitted to the hospital for surgical repair of patent ductusarteriosus. The child is being given digoxin. Prior to administering the medication, the nurseshould:
A. Not give the digoxin if the pulse is_60
B. Not give the digoxin if the pulse is_100
C. Take the apical pulse for a full minute
D. Monitor for visual disturbances, a side effect of digoxin
During the active phase of rheumatic fever, the nurse teaches parents of a child with acute rheumatic fever to assist in minimizing joint pain and promoting healing by:
A. Putting all joints through full range-of-motion twice daily
B. Massaging the joints briskly with lotion or liniment after bath
C. Immobilizing the joints in functional position using splints, rolls, and pillows
D. Applying warm water bottle or heating pads over involved joints
A 4 year old has an imaginary playmate, which concerns the mother. The nurse’s bestresponse would be:
A. “I understand your concern and will assist you with a referral.”
B. “Try not to worry because you will just upset your child.”
C. “Just ignore the behavior and it should disappear by age 8.”
D. “This is appropriate behavior for a preschooler and should not be a concern.”
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.” The nurse’s best response would be:
A. “That might be a problem. Tell me more about them.”
B. “Risk factors can often be controlled by self-responsibility.”
C. “It sounds like you’re intellectualizing your drinking problem.”
D. “Your grandfather and father were both alcoholics?”
The nurse writes the following nursing diagnosis for a client in acute renal failure—Impairedgas exchange related to:
A. Decreased red blood cell production
B. Increased levels of vitamin D
C. Increased red blood cell production
D. Decreased production of renin
Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?
A. Urine output 22 mL/hr for 2 hours
B. Serum potassium level of 3.7
C. Small T wave of ECG
D. Serum glucose level of 180
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She hasbeen admitted to the pediatric unit after surgical repair of the cleft lip. Which of the followingnursing interventions would be appropriate during the first 24 hours?
A. Position on side or abdomen.
B. Maintain elbow restraints in place unless she is being directly supervised.
C. Clean suture line every shift.
D. Offer pacifier when she cries.