NCLEX Exercise of the Day 47th Edition 2019 / 2020 / 2021
NCLEX Exercise of the Day 47th Edition 2019 / 2020 / 2021
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| NCLEX Exercise of the Day 47th Edition 2019 / 2020 / 2021 |
1. A nurse reinforces feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, the nurse tells the mother to:
A. Thin the feedings by adding water to the formula
B. Thicken the feedings by adding rice cereal to the formula
C. Provide less frequent, larger feedings
D. Have the infant burp less frequently during feedings
Answer: B. Thicken the feedings by adding rice cereal to the formula
Rationale: Small, more frequent feedings with frequent burping are often tried as the first line of treatment in GER. Feedings thickened with rice cereal may reduce episodes of emesis. Thickened feedings do not affect reflux time, however. If thickened formula is prescribed, 1 to 3 teaspoons of rice cereal per ounce of formula is most commonly used and may require cross-cutting of the nipple. Options 1, 3, and 4 are incorrect.
Test-Taking Strategy: Use basic principles related to feeding an infant to assist in eliminating options 3 and D. Noting the key words reducing the episodes of emesis will assist in directing you to select option 2 from the remaining options. Review therapeutic interventions associated with this disorder 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. 665.
2. A nurse reinforces instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse tells the parents that the infant should be maintained in:
A. A 30-degree angle when supine
B. A 60-degree angle when prone
C. An upright angle 24 hours a day
D. A 20-degree angle when in the lateral position
Answer: C. An upright angle 24 hours a day
Rationale: Proper positioning is an important component of reflux management. Ideally, the goal is to maintain the infant in an upright angle 24 hours a day, at a 60-degree angle when supine, and at a 30-degree angle when prone. This position is maintained until the infant remains asymptomatic for 6 weeks.
Test-Taking Strategy: Use the process of elimination. Recalling that an upright position will prevent reflux will direct you to option C. Review positioning for GER 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. 665.
3. A nurse is assigned to care for a child with hypertropic pyloric stenosis. The child is scheduled for pyloromyotomy. Which of the following positions would the nurse place the child during the preoperative period?
A. Prone with the head of the bed elevated
B. Prone with the head of the bed lowered to promote drainage
C. Supine with the head of the bed at a 30-degree angle
D. Supine with the head of the bed at a 45-degree angle
Answer: A. Prone with the head of the bed elevated
Rationale: In the preoperative period, the infant is positioned prone with the head of the bed elevated to reduce the risk of aspiration. Options 2, 3, and 4 are inappropriate positions to prevent this risk.
Test-Taking Strategy: Visualize each of the positions. Eliminate options 3 and 4 first because they are similar. From the remaining options, keeping in mind that aspiration is the concern will direct you to option A. Review preoperative care for pyloromyotomy if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
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. 1139.
4. A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which of the following foods would the nurse instruct the mother to avoid?
A. Hard cheeses
B. Green, leafy vegetables
C. Dried beans
D. Egg yolks
Answer: A. Hard cheeses
Rationale: Breast-feeding mothers of infants with lactose intolerance need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources include egg yolks; green, leafy vegetables; dried beans; cauliflower; and molasses.
Test-Taking Strategy: Note the key word avoid. These words indicate a false response question and that you need to select the incorrect food item. Knowledge that lactose is the sugar found in dairy products will direct you to option A. Review the dietary management for lactose intolerance 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. 1145.
5. A nurse reviews the record of a 1-year-old child seen in the clinic and notes that the physician has documented a diagnosis of celiac crisis. Which of the following symptoms would the nurse expect to note in this condition?
A. Anorexia
B. Joint pain
C. Profuse, watery diarrhea
D. Constipation
Answer: C. Profuse, watery diarrhea
Rationale: Clinical manifestations associated with celiac crisis include profuse, watery diarrhea and vomiting that quickly lead to severe dehydration and metabolic acidosis. The cause of the crisis is usually infection or ingestion of hidden sources of gluten. The child may require intravenous fluids to correct fluid and acid/base imbalances, albumin to treat shock, and corticosteroids to decrease severe mucosal inflammation.
Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with celiac crisis is required to answer the question. Recalling that celiac disease causes diarrhea, then it is likely that crisis will lead to exaggeration of this symptom. Review this disorder 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
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 660.
Source : NCLEX example quiz and answer
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