NCLEX Practice Questions Free 48th Edition

NCLEX Practice Questions Free 48th Edition

1. A nurse is assisting a physician with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the physician palpates the child at McBurney point. The nurse knows that McBurney point is located midway between the:

A. Right anterior inferior iliac crest and the umbilicus
B. Left anterior superior iliac crest and the umbilicus
C. Right anterior superior iliac crest and the umbilicus
D. Left anterior superior iliac crest and the umbilicus

Answer: C. Right anterior superior iliac crest and the umbilicus

Rationale: McBurney point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. Options 1, 2, and 4 are incorrect.

Test-Taking Strategy: Use the process of elimination. Knowledge that the appendix is located in the right side of the abdomen will assist in eliminating options 2 and D. From this point, visualize this assessment procedure. This will assist in directing you to option C. Review this assessment technique if you had difficulty with this question.

Level of Cognitive Ability: Knowledge
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. 675.

2. A mother of an infant diagnosed with Hirschsprung’s disease asks the nurse about the disorder. The nurse plans to base the response on which of the following?

A. It is a congenital aganglionosis or megacolon
B. It is a complete small intestinal obstruction
C. It is a condition that causes the pyloric valve to remain open
D. It is a severe inflammation of the gastrointestinal tract

Answer: A. It is a congenital aganglionosis or megacolon

Rationale: Hirschsprung’s disease, also known as congenital aganglionosis or megacolon, is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 2, 3, and 4 are incorrect.

Test-Taking Strategy: Knowledge regarding the pathophysiology associated with Hirschsprung’s disease is required to answer this question. Remember, Hirschsprung’s disease is the result of an absence of ganglion cells in the rectum. Review the characteristics of this disease if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 155-156.

3. A nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. The nurse understands that which of the following is unassociated with this disorder?

A. The presence of stool in the urine
B. Failure to pass a rectal thermometer
C. Failure to pass meconium in the first 24 hours after birth
D. The passage of currant jelly-like stools

Answer: D. The passage of currant jelly-like stools

Rationale: During the newborn assessment, this defect should be easily identified on site. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. The presence of stool in the urine or vagina should be reported immediately as an indication of abnormal anorectal development. Currant jelly-like stools are not a clinical manifestation of this disorder.

Test-Taking Strategy: Note the key word unassociated. This word indicates a false response question and that you need to select the incorrect clinical manifestation. Use the definition of the word “imperforate” to assist in directing you to option D. Review the important assessment data associated with 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: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1116.

4. A nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which of the following is the appropriate nursing intervention?

A. Notify the registered nurse immediately
B. Document the findings
C. Apply ice immediately
D. Elevate the buttocks

Answer: B. Document the findings

Rationale: A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate interventions.

Test-Taking Strategy: Focus on the data in the question. Note the key words returns from surgery. You would expect redness and edema at this time. Review postoperative colostomy assessment 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: Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, pp. 469-470.

5. A nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further instructions?

A. “I need to use only dilators supplied by the physician.”
B. “I need to use a water-soluble lubricant.”
C. “I will insert the dilator no more than 1 to 2 cm into the anus.”
D. “I will insert a glycerin suppository before the dilation.”

Answer: D. “I will insert a glycerin suppository before the dilation.”

Rationale: Following this surgery, anal dilation at home by the parents is necessary to achieve and maintain bowel patency. Inserting a glycerin suppository before the dilation is not a component of this procedure. Options 1, 2, and 3 are accurate instructions and will prevent damage to the rectal mucosa.

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 statement. Visualize each statement in the options to direct you to option D. Review this procedure 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
References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1119.
Wong, D., & Hockenberry, M. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby, p. 470.

Source : NCLEX example quiz and answer

Read also:

• NCLEX Exercise of the Day 47th Edition 2019 / 2020 / 2021
• Example NCLEX RN Question with Answer and Rationale 46th Edition
• NCLEX RN Question of The Day 45th Edition (August 2019)
• NCLEX RN Question of The Day 44th Edition

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