NCLEX Question and Answer with Rationale 2019 / 2020 / 2021 / 2020 / 2023 26th Edition

NCLEX Question and Answer with Rationale 2019 / 2020 / 2021 / 2020 / 2023 26th Edition

NCLEX Question and Answer with Rationale 2019 / 2020 / 2021 / 2020 / 2023 26th Edition

1. A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is:

A. A disease that causes the formation of multiple cysts in the lungs
B. A chronic multisystem disorder affecting the exocrine glands
C. Transmitted as an autosomal dominant trait
D. A disease that causes dilation of the passageways of many organs

Answer: B. A chronic multisystem disorder affecting the exocrine glands

Rationale: Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

Test-Taking Strategy: Knowledge regarding the physiology associated with cystic fibrosis is required to answer this question. If you knew that it was a multisystem disorder, you would easily be directed to option B. Additionally, option 2 is the umbrella (global) option. Review the physiology associated with this disorder if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 144.



2. A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis (CF). Which test result is suggestive of cystic fibrosis and will require further assessment and investigation?

A. Chloride level of 5 mEq/L
B. Chloride level of 10 mEq/L
C. Chloride level of 20 mEq/L
D. Chloride level of 40 mEq/L

Answer: D. Chloride level of 40 mEq/L

Rationale: In a sweat test, sweating is stimulated on the child’s forearm with pilocarpine, the sample is collected on absorbent material, and the amount of sodium and chloride is measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level greater than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L is suggestive of CF and requires a repeat test. Options 1, 2, and 3 do not identify results that are positive for CF.

Test-Taking Strategy: Note the key word suggestive. Based on the issue of this question, it is best to select the highest level. Review the interpretation of these test results if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
References:

• Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 609.
• Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 146.

3. A nurse is providing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the mother?

A. “The immunization schedule will need to be altered.”
B. “The child will receive all of the immunizations except for the polio series.”
C. “The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination.”
D. “The child should not receive any hepatitis vaccines.”

Answer: B. “The child will receive all of the immunizations except for the polio series.”

Rationale: It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis should also receive yearly influenza vaccines.

Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are similar. Recalling the importance of protection from communicable diseases, particularly in children with a disorder such as cystic fibrosis, will assist in directing you to option C. Review the guidelines for the administration of immunizations if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1244.



4. A nurse teaches a child with cystic fibrosis how to perform the “huff” maneuver and tells the child to take a:

A. Deep breath, hold it for 15 seconds, and then exhale slowly, whispering the word “huff.”
B. Shallow breath and then exhale rapidly, whispering the word “huff.”
C. Deep breath and then exhale rapidly, whispering the word “huff.”
D. Shallow breath, hold it for 10 seconds, and then exhale rapidly, whispering the word “huff.”

Answer: C. Deep breath and then exhale rapidly, whispering the word “huff.”

Rationale: The “huff” maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath and then exhaling rapidly, whispering the word “huff.”

Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first by recalling that shallow breathing is ineffective in promoting the mobilization of secretions. Select option 3 over option 1 based on the knowledge that exhaling rapidly will assist in reducing bronchial collapse and mobilize secretions. Holding the breath will not achieve this physiological function. Recalling that the “huff” maneuver is also known as a forced expiratory technique will direct you to the correct option. Review this technique if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1244.




5. The mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8 AM, noon, and 6 PM. The nurse tells the mother that the postural drainage should be performed at:

A. 10 AM, 2 PM, and 8 PM
B. 9 AM, 1 PM, and 6 PM
C. 8 AM, noon, and 6 PM
D. 8 AM, 2 PM, and 6 PM

Answer: A. 10 AM, 2 PM, and 8 PM

Rationale: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.

Test-Taking Strategy: Visualize the procedure of postural drainage in answering the question. Recalling that this position may induce vomiting will assist in eliminating options 2, 3, and D. Review this procedure if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 610.

Source : NCLEX example quiz and answer

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