Example NCLEX RN Question with Answer and Rationale 46th Edition
Example NCLEX RN Question with Answer and Rationale 46th Edition
1. A 3-year-old child is hospitalized because of persistent vomiting. Which of the following conditions would the nurse expect to occur in this child?
A. Diarrhea
B. Metabolic acidosis
C. Metabolic alkalosis
D. Hyperactive bowel sounds
Answer: C. Metabolic alkalosis
Rationale: Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea may not accompany vomiting. Hyperactive bowel sounds are not specifically associated with vomiting.
Test-Taking Strategy: Use the process of elimination. Recalling that gastric fluids are acidic in nature and that the loss of these fluids will lead to alkalosis will assist in answering the question. There are no supporting data in the question to support options 1 and D. Review the manifestations that occur with vomiting 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
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 664.
2. A nurse is monitoring for fluid volume deficit in an infant. The nurse weighs the infant’s diaper after each voiding and carefully calculates fluid volume knowing that:
A. Each gram of diaper weight is equivalent to 0.5 mL of urine
B. Each gram of diaper weight is equivalent to 1 mL of urine
C. Each gram of diaper weight is equivalent to 2 mL of urine
D. Each gram of diaper weight is equivalent to 2.5 mL of urine
Answer: B. Each gram of diaper weight is equivalent to 1 mL of urine
Rationale: When monitoring for fluid volume deficit, the nurse should weigh the infant’s diaper after each voiding. Each gram of diaper weight is equivalent to 1 mL of urine.
Test-Taking Strategy: Specific knowledge regarding the measurements related to monitoring for fluid volume deficit is required to answer this question. Remember that each gram of diaper weight is equivalent to 1 mL of urine. Review this information if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 1086-1087.
Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 1186.
3. A nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further instructions?
A. “I need to use a nipple with a small hole to prevent choking.”
B. “I need to stimulate sucking by rubbing the nipple on my infant’s lower lip.”
C. “I need to allow my infant time to swallow.”
D. “ I need to allow my infant to rest frequently to provide time for swallowing what has been placed in the mouth.”
Answer: A. “I need to use a nipple with a small hole to prevent choking.”
Rationale: The mother should be taught the ESSR method of feeding the infant with a cleft palate. ENLARGE the nipple by cross-cutting a hole so that food is delivered to the back of the throat without sucking. STIMULATE sucking by rubbing the nipple on the lower lip. SWALLOW. REST to allow the infant to finish swallowing what has been placed in the mouth.
Test-Taking Strategy: Note the key words need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Eliminate options 3 and 4 first because they are similar. Use basic principles regarding the methods to stimulate sucking to eliminate option B. Review teaching guidelines for the infant with cleft lip or palate if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 96-98.
4. Following a cleft lip repair, the nurse reinforces instructions to the parents regarding cleaning of the lip repair site. Which of the following solutions would the nurse use in demonstrating this procedure to the parents?
A. Tap water
B. Sterile water
C. Full strength hydrogen peroxide
D. Half strength hydrogen peroxide
Answer: B. Sterile water
Rationale: The lip repair site is cleansed with sterile water using a cotton swab after feeding and as prescribed. The parents should be instructed to use a rolling motion from the suture line out. The parents should also demonstrate performance of the correct procedure to the nurse.
Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar. From the remaining options, recall the importance of asepsis to a surgical site. This concept will direct you to option B. Review this procedure 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: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 96.
5. An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids and a gastrostomy tube is in place. The nurse who is assisting in caring for the infant will ensure that the gastrostomy tube is:
A. Placed to gravity
B. Attached to low suction
C. Taped to the bed linens
D. Elevated
Answer: D. Elevated
Rationale: In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass to the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. Options 1, 2, and 3 are incorrect.
Test-Taking Strategy: Use the process of elimination. Option 3 can be easily eliminated because this action could cause accidental removal of the tube. Option 2 can be eliminated next, recalling that suction on a surgical site could disrupt the repair. From the remaining options, recalling that gastrostomy tubes are not normally attached to gravity flow will assist in directing you to the correct option. Review postoperative nursing care 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: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1113.
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