Quiz of NCLEX RN with Best Answer and Rationale 31th Edition
Quiz of NCLEX RN with Best Answer and Rationale 31th Edition
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| Quiz of NCLEX RN with Best Answer and Rationale 31th Edition |
1. An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dl. The appropriate intervention is to:
A. Keep the child NPO
B. Contact the physician
C. Give the child a glass of juice
D. Let the child rest until the dizziness subsides
Answer: C. Give the child a glass of juice
Rationale: A blood glucose level below 70 mg/dl indicates hypoglycemia. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 1, 2, and 4 do not address the hypoglycemic condition.
Test-Taking Strategy: Identify the issue of the question—a hypoglycemic condition. Options 1, 2, and 4 do not address treatment of the hypoglycemia. Review the signs and treatment for hypoglycemia 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. 285.
2. A child with diabetes mellitus is brought to the emergency room by her mother who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting to care for the child checks the intravenous (IV) and medication supply area for which of the following?
A. 5% dextrose IV infusion
B. 0.9% normal saline IV infusion
C. NPH insulin
D. Potassium
Answer: B. 0.9% normal saline IV infusion
Rationale: Rehydration is the initial step in resolving DKA. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route and is not used to treat DKA. Dextrose solutions are added to the treatment when the blood glucose levels reach an acceptable level. IV potassium may be required depending on the potassium level, but would not be part of the initial treatment.
Test-Taking Strategy: Use the process of elimination. Eliminate option 1 by knowing that dextrose would not be administered in a hyperglycemic state. Eliminate option 3 next by knowing that NPH insulin is never administered by the IV route and is not used to treat DKA. From the remaining options, recalling that hydration is the initial treatment in DKA will direct you to option B. Review the treatment for DKA if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
References:
- McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1480.
- Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 282.
3. A physician has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. The nurse responds by telling the mother that surgery will probably be performed:
A. Immediately
B. Shortly before the child starts school
C. Before the child is 2 years old
D. Just before the child begins to learn to read
Answer: C. Before the child is 2 years old
Rationale: In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 2 years old.
Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated first because of the word immediately. Options 2 and 4 can be eliminated next because they address a similar time frame. Review the treatment for strabismus 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. 229.
4. A physician prescribes “eye patching” for a child with strabismus of the right eye. The nurse instructs the mother regarding this procedure and tells the mother to:
A. Place the patch on the right eye
B. Place the patch on both eyes
C. Place the patch on the left eye
D. Alternate the patch from the right to left eye hourly
Answer: C. Place the patch on the left eye
Rationale: Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the “good” eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.
Test-Taking Strategy: Use the process of elimination. Remembering that this condition is a “lazy eye” will direct you to the correct option. It makes sense to patch the unaffected eye in order to strengthen the muscles in the affected eye. Review the procedure for patching if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 541.
5. The mother of a 6-year-old child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which of the following would require further investigation?
A. The presence of an allergy
B. Possible trauma
C. Possible sexual abuse
D. The presence of a respiratory tract infection
Answer: C. Possible sexual abuse
Rationale: A diagnosis of chlamydial conjunctivitis in a non–sexually-active child should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis but not in chlamydial form.
Test-Taking Strategy: Note the age of the child and the organism that is identified in the question. This will assist in directing you to option C. Options 1, 2, and 4 should be recognized as the common causes of conjunctivitis. These options are similar in that they all relate to a physiological problem. Review content related to chlamydial conjunctivitis if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial 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. 1041.
Source : NCLEX example quiz and answer
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