NCLEX RN Pediatric Questions

NCLEX RN Pediatric Questions Related

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Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?

  • A. Restrict fluid intake
  • B. Ensure that the client avoids prolonged sitting
  • C. Position lower extremities below level of heart
  • D. Instruct the client to avoid leg exercises
Correct Answer: C

Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.

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These facts are true regarding the developmental stage of preschool children EXCEPT

  • A. handedness is achieved by 3 years of age
  • B. boys are usually later than girls in achieving bladder control
  • C. knowing gender by 4 years
  • D. musturbation
Correct Answer: D

Rationale: Musturbation is not a recognized developmental milestone.

Which of the following types of translocation of childhood AML that typically associated with granulocytic sarcoma mass?

  • A. inv(16)
  • B. t(8;21)
  • C. t(6;9)
  • D. inv(3)
Correct Answer: A

Rationale: The inv(16) translocation is strongly associated with granulocytic sarcoma in AML.

In a newborn's eyes, strabismus is a normal finding because of:

  • A. congenital cataracts.
  • B. lack of binocularity.
  • C. absence of red reflex.
  • D. inability of pupil to react to light.
Correct Answer: B

Rationale: Strabismus, or misalignment of the eyes, is a common condition in newborns due to the lack of binocularity. Binocularity refers to the ability of both eyes to focus simultaneously on a single point, which is not fully developed in newborns. As a result, it is normal for a newborn's eyes to appear misaligned at times. This lack of coordination between the eyes typically resolves as the infant's visual system matures and they develop the ability to focus both eyes together. Therefore, the presence of strabismus in a newborn is usually considered a normal finding related to the immature visual development rather than a sign of pathology such as congenital cataracts, absence of red reflex, or pupil reactivity issues.

The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient's gastrointestinal tract is resuming normal function?

  • A. Firm abdomen
  • B. Presence of flatus
  • C. Excessive thirst
  • D. Absent bowel sounds
Correct Answer: B

Rationale: The presence of flatus (gas) is a positive sign that the patient's gastrointestinal tract is resuming normal function after a bowel resection surgery. Flatus production indicates that peristalsis and normal bowel motility are returning, allowing gas to move through the intestine. This is an important milestone in the postoperative recovery process, as it suggests the return of normal bowel function. The other options provided are not indicative of the return of normal gastrointestinal function.

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

  • A. "Keep the stoma uncovered."
  • B. "Keep the stoma dry."
  • C. "Have a family member perform stoma care initially until you get used to the procedure."
  • D. "Keep the stoma moist."
Correct Answer: B

Rationale: It is important to keep the stoma dry to prevent infection and skin irritation. Excess moisture can lead to skin breakdown around the stoma site, increasing the risk of infection. It is recommended to keep the stoma clean and dry to promote healing and prevent complications.

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