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NCLEX RN Questions and Answers Free Download 4th Edition
1. A nurse is caring for a hospitalized child with a history of seizures who is receiving phenytoin sodium (Dilantin). Which of the following would be included in the plan of care for this child?
A. Monitoring intake and output
B. Checking the blood pressure before administering the phenytoin
C. Providing oral hygiene, especially care of the gums
D. Administering medications 1 hour before food intake
Answer: C. Providing oral hygiene, especially care of the gums
Rationale: Phenytoin sodium causes gum bleeding and hypertrophy, and therefore oral hygiene is important. Soft toothbrushes and gum massage should be instituted to reduce the risk of complications and prevent further trauma. Options 1 and 2 are incorrect because the intake and output as well as blood pressure are not affected by this medication. Option 4 is incorrect because directions for administration of this medication include dispensing with food to minimize gastrointestinal upset.
Test-Taking Strategy: Knowledge of the side effects and method of administering oral phenytoin sodium is required to answer this question. Remember, phenytoin causes gum bleeding and hypertrophy, and therefore oral hygiene is important. If you had difficulty with this question, review the side effects of this medication.
Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 858.
2. A nurse is caring for a child receiving carbamazepine (Tegretol) who has a carbamazepine level drawn. Which of the following results indicates a therapeutic level?
A. 1 mcg/mL
B. 3 mcg/mL
C. 6 mcg/mL
D. 15 mcg/mL
Answer: C. 6 mcg/mL
Rationale: When carbamazepine is administered, blood levels need to be drawn periodically to check for the child’s absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum level for this medication is 4 to 12 mcg/mL.
Test-Taking Strategy: Knowledge of the therapeutic serum level for this medication will assist in selecting the correct option. Remember, the therapeutic serum level for this medication is 4 to 12 mcg/mL. If you had difficulty with this question, review this therapeutic level.
Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 166.
3. A nurse is developing a plan of care for a child with autism. The nurse identifies which of the following as the priority problem for this child?
A. Impaired social interaction
B. Risk for injury
C. Disturbed thought processes
D. Impaired verbal communication
Answer: B. Risk for injury
Rationale: Risk for injury related to an inability to anticipate danger, a tendency for self-mutilation, and sensory perceptual deficits is the priority concern. Impaired social interaction, disturbed thought processes, and impaired verbal communication are also appropriate problems for the child with autism, but the priority is the risk for injury.
Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer this question. Physiological needs take priority. When a physiological need does not exist, safety needs are the priority. None of the options address a physiological need. Option 2 addresses the safety need. Review care to the child with autism if you had difficulty with this question.
Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 763.
4. A nurse assisting is collecting data on a child and suspects physical abuse. The nurse understands that which of the following is a primary and legal nursing responsibility?
A. Document the child’s physical assessment findings accurately and thoroughly
B. Report the case in which the abuse is suspected
C. Refer the family to the appropriate support groups
D. Assist the family in identifying resources and support systems
Answer: B. Report the case in which the abuse is suspected Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.
Test-Taking Strategy: Use the process of elimination, noting the key words primary and legal. In addition to the many implications associated with child abuse, abuse is a crime. With this in mind, option 2, reporting the case of abuse, is the primary responsibility. If you had difficulty with this question, review the responsibilities of the nurse when child abuse is suspected.
Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 586-587.
5. A nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig’s sign. The appropriate procedure to elicit Kernig’s sign is to:
A. Bend the head towards the knees and hips and check for pain
B. Tap the facial nerve and check for spasm
C. Compress the upper arm and check for tetany
D. Extend the leg and knee and check for pain
Answer: D. Extend the leg and knee and check for pain
Rationale: Kernig’s sign is pain that occurs with extension of the leg and knee. Brudzinski’s sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.
Test-Taking Strategy: Knowledge regarding the appropriate procedure to elicit Kernig’s sign is needed to answer the question. Remember, Kernig’s sign is pain that occurs with extension of the leg and knee. If you had difficulty with this question, review these signs, their significance, and the procedure to elicit these signs.
Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1524.
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