NCLEX Questions and answer Update December 2019 for 2020/2021

NCLEX Questions and answer Update December 2019 for 2020/2021

1. A 1-year old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse would avoid doing which of the following to protect the infant from injury?

A. Keep a padded tongue blade at the bedside for use during a seizure
B. Refrain from giving the infant toys to play with that have bright blinking lights on them
C. Keep the side rails and other hard objects padded
D. Turn the infant to the side during a seizure

Answer: A. Keep a padded tongue blade at the bedside for use during a seizure

Rationale: Attempting to place something in a child’s mouth during a seizure in not helpful even if it is padded. The mouth is usually clenched and one would have to use force to open the mouth. The nurse must attempt to keep the airway clear and can do that by positioning (option 4). Option 2 may be helpful in preventing a seizure, and option 3 safeguards the client’s physical safety.

Test-Taking Strategy: Use the process of elimination and note the key word avoid. This word indicates a false-response question and that you need to select the incorrect action. With this in mind, eliminate options 3 and 4, which are obviously helpful actions. Choose between the remaining options knowing that either tongue blades can be dangerous or that avoiding toys with lights would be a helpful intervention. Review seizure precautions 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: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 550.

2. A 1-year old child who was born 2 months premature is hospitalized. The nurse would plan to encourage the child to do which of the following to maintain developmental skills while hospitalized?

A. Sit independently
B. Build a tower of three blocks
C. Indicate wants by pointing or grunting
D. Walk independently

Answer: A. Sit independently

Rationale: For premature infants, calculate the developmental age by deducting the time of prematurity from the age of the child until they reach the age of 2 years. In this case subtract 2 months from 1 year to equal 10 months of age. A 10-month-old can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of three blocks.

Test-Taking Strategy: Use knowledge of how to calculate the developmental age of the prematurely born child and concepts of growth and development to answer this question. This will direct you to option A. Review this content if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.).
Philadelphia: W.B. Saunders, pp. 388, 39C.

3. A nurse is collecting data on a client who is pregnant with twins. Which of the following signs would alert the nurse to a potential problem specifically related to the twin pregnancy?

A. Hypertension
B. Uterine size is large for gestational age
C. Slightly elevated blood glucose level
D. Mother is Rh negative

Answer: A. Hypertension

Rationale: The mother with a multiple-gestation pregnancy is at a higher risk for preeclampsia than if she had a singleton pregnancy. Maternal well-being should be monitored for signs and symptoms of preeclampsia and preterm labor. A classic sign of preeclampsia is hypertension. A slightly elevated blood glucose level and Rh sensitization are concerns, but are not unique to a multiple pregnancy. Uterine size may be large for gestational age in a multiple-gestation pregnancy.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the risks associated with a multiple-gestation pregnancy to answer this question. Recalling that the client is at increased risk for preeclampsia will direct you option A. Review the risks associated with a multiple-gestation pregnancy if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 838, 1003.

4. A nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which of the following would the nurse expect to note when collecting data on the client?

A. Elevated blood pressure, proteinuria, and edema
B. Regression of pregnancy symptoms and absence of fetal heart tones
C. Uterine size greater than expected for gestational age
D. Intractable vomiting and dehydration

Answer: B. Regression of pregnancy symptoms and absence of fetal heart tones

Rationale: Symptoms of an intrauterine fetal demise include decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. Many symptoms of pregnancy may diminish, such as uterine size and breast size and tenderness. Option 1 identifies signs of preeclampsia. Option 4 is associated with hyperemesis gravidarum.

Test-Taking Strategy: It is important to know that fetal demise means fetal death. Note the relationship between “fetal demise” in the question and “absence of fetal heart tones” in the correct option. Review the signs associated with fetal demise if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: Lowdermilk, D., & Perry, S.E. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, pp. 876-877.

Read also:

• Free NCLEX Test with Answer 2020/ 2021 130th Edition
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• Free NCLEX Exam in Multiple Choice 128th Edition

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