NCLEX RN JULY 2022 - CHRISJAY FILES The nurse is completing an asses...

CHRISJAY FILES

NCLEX RN JULY 2022

TESTED THIS JULY

QUESTIONS AND ANSWERS

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CHRISJAY FILES

The nurse is completing an assessment of a child in the clinic. Which of the following should be documented in the child's health history? Select all that apply.

1.‐ The child was born by cesarean section.

2.‐ Mother states child has a rash 3.‐ Child appears feverish 4.‐ Diminished reflexes 5.‐ Older sister had the chicken pox recently.

A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that:

• Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
• Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
• It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
• He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day

A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?

• By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
• The same nurses will prevent parental fatigue and frustration.
• The same nurses will prevent infant fatigue and frustration.
• Primary nurses will ensure privacy.

The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?

• Patience by the child when wearing soiled diapers
• Communicating the urge to defecate or urinate
• The child awakening wet from his naps
• The age at which the child's siblings were trained

A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale?

• To reduce fear of the unknown
• To keep the child calm
• To establish a trusting relationship 2 / 4

CHRISJAY FILES

• To prevent or minimize separation anxiety

A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate?

• Monitoring the temperature prevents undue chilling.
• Rapid temperature elevations can occur in children.
• Checking the temperature will prevent febrile seizures.
• Taking the child's temperature can prevent airway obstruction.

The nurse is teaching a group of adults about health screenings for cancer. The nurse would include in the discussion which of the following points?Select all that apply.

1.‐ Genetic screening is helpful in identification of cancer risks.

2.‐ Annual medical exams uncover most tumors.

3.‐ Men need to perform breast and testicle exams monthly.

4.‐ Annual mammograms are recommended after a total mastectomy.

5.‐ Inspection of the skin for cancer becomes less important as one ages.

A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?

• Hold the child's discharge for 1 hour.
• Notify the physician immediately.
• Discharge the child as the physician ordered.
• Administer an antiemetic as necessary.

A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss.Identify the number-one priority nursing diagnosis.

• Fluid volume deficit
• Altered nutrition
• Altered bowel elimination
• Anxiety

A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:

• Respiratory acidosis 3 / 4

CHRISJAY FILES

• Respiratory alkalosis
• Metabolic acidosis
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