Study NCLEX PN Questions with Answers 97th Edition

Study NCLEX PN Questions with Answers 97th Edition

1. A nurse is reviewing the record of a child scheduled for a physician’s visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which of the following when collecting data?

A. Bowel function
B. Bladder function
C. Nutritional status and weight gain
D. Motor development

Answer: B. Bladder function

Rationale: Enuresis refers to a condition in which the child is unable to control bladder function although he or she has reached an age at which control of voiding is expected. Nocturnal enuresis or bed-wetting is common in children.

Test-Taking Strategy: If you are unfamiliar with the term enuresis, use medical terminology and break the word down into parts. Associate the word with the urinary system to assist in directing you to the correct option. 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: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 217.

2. A nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which of the following locations would the nurse select to administer the medication?

A. Ventrogluteal muscle
B. Deltoid muscle
C. Dorsogluteal muscle
D. Vastus lateralis muscle

Answer: D. Vastus lateralis muscle

Rationale: The vastus lateralis muscle is the best choice for all age groups and should always be used in children younger than 3 years of age. The ventrogluteal muscle is safe for children older than 18 months because it is free of major blood vessels and nerves. The dorsogluteal muscle develops with walking, so it should not be used until the child has been walking for at least 1 year. The deltoid muscle is not used for children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into the muscle mass.

Test Taking Strategy: Focus on the age of the child identified in the question to assist in directing you to the correct option. Remember, the vastus lateralis muscle is the best choice for all age groups and should always be used in children younger than 3 years of age. If you are unfamiliar with this procedure, review this content.

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, pp. 366-367.

3. A nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse would place the client in which position during and after the feedings?

A. Supine
B. Fowler’s
C. Sims
D. Trendelenburg

Answer: B. Fowler’s

Rationale: The client is placed with the head of the bed elevated 30 to 45 degrees both during and after feedings to prevent aspiration. The positions identified in options 1, 3, and 4 place the client at risk for aspiration.

Test-Taking Strategy: Think about the risks associated with tube feedings. Recalling that the risk of aspiration exists will direct you to option B. Review care to the client receiving tube feedings if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Gastrointestinal
Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 481.

4. A client is being prepared for electroconvulsive therapy (ECT). The nurse’s plan of care for the night before ECT treatment includes ensuring that the client:

A. Is placed on “nothing by mouth” status for 18 to 24 hours
B. Receives no visitors and participates in limited unit activities
C. Shampoos and dries hair, freeing it of all hair spray and creams
D. Does not smoke cigarettes

Answer: C. Shampoos and dries hair, freeing it of all hair spray and creams

Rationale: The client is instructed to shampoo and dry the hair the night before ECT treatment. In addition, the client is instructed not to use hair sprays or creams before ECT to reduce the risk of burns. While the client is NPO for 6 to 8 hours before treatment, the 18 to 24 hours identified in option 1 is not necessary. Some hospitals place inpatient clients on NPO status at midnight before ECT in the morning. Some clients who are on cardiovascular medication may be instructed to take their medicine with sips of water several hours before ECT. Option 2 is incorrect as is option 4, although smoking is always discouraged. In addition, informed consent, minimization of client and family anxieties and fears concerning the procedure, and keeping the client free from injury are treatment goals for the client undergoing ECT.

Test-Taking Strategy: Focus on knowledge of the pretreatment preparation for ECT to answer the question and use the process of elimination. Remember, the client is instructed to shampoo and dry the hair the night before ECT treatment to reduce the risk of burns. Review the preprocedure preparation for ECT if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed.). St. Louis: Mosby, p. 606.

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