Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition - NCLEX Exam Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition - NCLEX Exam

Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition

Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition


Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition
Saunders Comprehensive nclex NCLEX RN 2019 / 2020 / 2021 42th Edition


1. A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. The appropriate nursing response is which of the following?

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A. “Surgical repair cannot be performed.”
B. “Surgical repair is usually performed around 10 weeks of age.”
C. “Surgical repair is individualized and depends on the size of the infant.”
D. “Surgical repair will be done immediately; otherwise, the infant will not be able to eat.”

Answer: B. “Surgical repair is usually performed around 10 weeks of age.”

Rationale: Cleft lip repair is usually performed around 10 weeks of age. Early repair may improve bonding and makes feeding much easier. Cleft palate repair is individualized and based on the degree of deformity and the size of the child. Closure of the cleft palate is completed between the ages of 6 months and 2 years. Early closure of cleft palate facilitates speech development. Although repair of a cleft lip makes feeding easier and improves bonding, it is not necessary to perform the surgical procedure immediately.

Test-Taking Strategy: Use the process of elimination. Option 1 can be easily eliminated first. Eliminate option 4 next because this response is inaccurate and can cause alarm in the mother. From the remaining options, remember that cleft lip repair is usually performed around 10 weeks of age. This will direct you to option B. Review these surgical procedures if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial 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. 96.



2. A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse bases the response on which of the following characteristics of this disorder?

A. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm
B. Abdominal contents herniate through an opening of the diaphragm
C. Gastric contents regurgitate back into the esophagus
D. The esophagus terminates before it reaches the stomach

Answer: A. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm

Rationale: In a hiatal hernia, a protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm occurs. Option 2 describes a congenital diaphragmatic hernia. Option 3 describes gastroesophageal reflux. Option 4 describes esophageal atresia.

Test-Taking Strategy: Use the process of elimination. Careful reading of each option and noting the word “hiatal” in the question and “hiatus” in option 1 will direct you to the correct option. If you had difficulty with this question, review this disorder.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1115.



3. The mother of a child that had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the “tubes” fell out. The nurse makes which response to the mother?

A. “Replace the tubes immediately so that the created opening does not close.”
B. “This is an emergency and requires immediate intervention. Bring the child to the emergency room.”
C. “This is not an emergency. I will speak to the physician and call you right back.”
D. “Soak the tubes in alcohol for 1 hour before replacing them in the child’s ears.”

Answer: C. “This is not an emergency. I will speak to the physician and call you right back.”

Rationale: The size and appearance of the tympanostomy tubes should be described to the parents following surgery. They should be reassured that if the tubes fall out, it is not an emergency but that the physician should be notified. Options 1, 2, and 4 are incorrect.

Test-Taking Strategy: Use the process of elimination. Option 2 should be eliminated first because this will cause concern in the parent. Next, eliminate options 1 and 4 because they are similar and relate to replacing the tubes. Review home care instructions following this procedure 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. 1119.



4. A child is scheduled for a tonsillectomy in the “day stay” surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has very bad mouth odor. The nurse makes which response to the mother?

A. “The child probably has an infection.”
B. “You need to contact the physician immediately.”
C. “Bad mouth odor is normal and may be relieved by drinking more liquids.”
D. “Have the child gargle with mouthwash.”

Answer: C. “Bad mouth odor is normal and may be relieved by drinking more liquids.”

Rationale: Bad mouth odor is normal following a tonsillectomy and may be relieved by drinking more liquids. Options 1, 2, and 4 are incorrect. Additionally, mouthwash gargles will irritate the throat.

Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first knowing that mouthwash gargles will irritate the surgical site. Options 1 and 2 are similar and can be eliminated; these responses will cause additional concern in the mother. Review postoperative expectations following a tonsillectomy 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. 1203.



5. A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which of the following that is a characteristic of this disease?

A. Increased hematocrit count
B. Increased platelet count
C. Increased reticulocyte count
D. Increased hemoglobin count

Answer: C. Increased reticulocyte count

Rationale: A laboratory diagnosis is established on the basis of a complete blood cell count, examination for sickled red blood cells (RBCs) on the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin, hematocrit, and platelet counts; an increased reticulocyte count; and the presence of nucleated red blood cells. Elevated reticulocyte counts occur in children with sickle cell disease because the lifespan of their sickled RBCs is shortened.

Test-Taking Strategy: Recalling the pathophysiology associated with sickle cell disease will assist in answering this question. Remember, elevated reticulocyte counts occur in children with sickle cell disease. Review the characteristics of this disease 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: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1307.


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