Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 91

1. A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:

A) Uses pictures to explain the procedure to the child and his parents that evening
B) Explains the procedure using simple words and sentences just before the preoperative sedation
C) Asks the parents to explain the procedure to the child after she explains it to them
D) Asks the parents to leave the room while the preoperative medication and instructions are given

2. Home-care instructions for the child following a cardiac catheterization should include:

A) Notify the physician if a slight bruise develops around the insertion site.
B) Use sponge bathing until stitches are removed.
C) Give aspirin if the child complains of pain at the insertion site.
D) Keep a clean, dry dressing on the insertion site for 2 days.

3. Nursing care for the parents of a child with a congenital heart defect would include:

A) Encouraging the parents not to tell the child about the seriousness of the congenital heart defect, so the child will function as normally as possible
B) Acknowledging the fear and concern surrounding their childs health and assisting the parents through the grieving process as they mourn the loss of their fantasized healthy child
C) Identifying anger and resentment as destructive emotions that serve no purpose
D) Expressing to the parents after the corrective surgery has been completed successfully that all their grief feelings will resolve

4. An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

A) If the infant vomits within 30 minutes of the digoxin administration, repeat the dose
B) They need to mix it with formula so the infant swallows it easily
C) If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify thephysician
D) If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed

5. A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:

A) Aplastic crisis
B) Vaso-occlusive crisis
C) Dactylitis crisis
D) Sequestration crisis

1. Right Answer: B
Explanation: (A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddlers need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the childs support system and need to be there to strengthen the child.

2. Right Answer: B
Explanation: (A) A small bruise may develop around the insertion site and is not a reason for alarm. (B) It is best to keep the child out of the bathtub until the sutures are removed. (C) Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. (D) The insertion site should be kept clean and dry and open to air.

3. Right Answer: B
Explanation: (A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child s care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'

4. Right Answer: C
Explanation: (A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.

5. Right Answer: D
Explanation: (A) Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 510 days. (B) Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. (C) Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. (D) Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.

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