NCLEX Practice Questions — Set 45
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. The nurse should do which of the following first?
Show answer and rationale
Correct answer: D. Place the toddler in a quiet environment.
One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child’s irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.
Which of the following should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged home?
Show answer and rationale
Correct answer: A. Take the child’s temperature daily for several days.
The child’s temperature should be taken daily for several days after discharge, because recurrent fever may develop. Offering the child fluids every 2 hours is not necessary. Doing so increases the child’s risk for CHF. Checking the child’s blood pressure at home usually is not included as part of the discharge instructions because, by the time of discharge, the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.
A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents?
Show answer and rationale
Correct answer: C. Explain that the high altitude may cause a crisis.
High altitude causes deoxygenation, which might precipitate a crisis. In clients with sickle cell anemia, cells sickle when the client experiences any situation where increased demand for oxygen is needed, such as in an infection or dehydration, or when low oxygen concentration is experienced, such as in high altitudes or deep sea diving. Crises can commonly be prevented by maintaining hydration. It would be unsafe to encourage the family, or to say nothing about taking the client to high altitude areas, but giving the parents adequate information will allow them to make an appropriate decision. Postponing the trip or leaving the child at home does not address the immediate concern for the child’s health.
Explain that the high altitude may cause a crisis.
Show answer and rationale
Correct answer: C. Drink at least 2 quarts of fluids per day.
Increasing fluid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell disease should stay away from others who have infections. When the spleen of a client who has sickle cell disease has become fibrotic and nonfunctional, the client is more susceptible to infections. Clients with sickle cell disease should not avoid physical activity as long as the client stays well hydrated.
The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
Show answer and rationale
Correct answer: C. Obstruction to circulation.
Characteristic sickle cells tend to cause "log jams" in capillaries. This results in poor circulation to local tissues, leading to ischemia and necrosis. The basic defect in sickle cell disease is an abnormality in the structure of the red blood cells. The erythrocytes are sickle-shaped, rough in texture, and rigid. Sickle cell disease is an inherited disease, not an autoimmune reaction. Elevated serum bilirubin concentrations are associated with jaundice, not sickle cell disease.
The mother asks the nurse why her child’s hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is appropriate?
Show answer and rationale
Correct answer: D. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."
Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn’s hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin. The gene for sickle cell disease is transmitted at the time of conception, not passed through the placenta. Some hemoglobin S is produced by the fetus near term. The fetus produces all its own hemoglobin from the earliest production in the first trimester. Passive immunity conferred by maternal antibodies is not related to sickle cell disease, but this transmission of antibodies is important to protect the infant from various infections during early infancy.
Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
Show answer and rationale
Correct answer: C. Both of the above
Parent teaching concerning a child with iron deficiency anemia should include directions about giving iron combined with fruit juice, in divided doses, between meals, and with a dropper for a 12-month-old or through a straw for older toddlers. Iron stains teeth; so brushing the teeth and administering liquid iron through a dropper or straw are necessary to prevent staining the teeth. Iron should not be given with milk, antacids, or tea and should be administered on an empty stomach. Iron will cause the stool to become black or green, which is normal and does not need to be reported. However, light-colored stools indicate the iron is not being absorbed and should be reported.
A mother asks the nurse if her child’s iron deficiency anemia is related to the child’s frequent infections. The nurse responds based on the understanding of which of the following?
Show answer and rationale
Correct answer: A. Children with iron deficiency anemia are more susceptible to infection than are other children.
Children with iron deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis.
Which statements by the mother of a toddler should lead the nurse to suspect that the child is at risk for iron deficiency anemia?
Show answer and rationale
Correct answer: A. Both of the above
Toddlers should have between two and three cups of milk per day and 8 oz of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients. Food preferences vary among children. It is acceptable for the child to refuse foods as long as the diet is balanced and contains adequate calories. The child is obtaining a normal amount of sleep.
Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency anemia?
Show answer and rationale
Correct answer: B. Macaroni, cheese, and ham.
Potatoes, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Milk and yellow vegetables are not good iron sources. Rice by itself also is not a good source of iron. Macaroni, cheese, and ham are not high in iron. While pudding (made with fortified milk) and green vegetables contain some iron, the better diet has protein and iron from the chicken and potato.
What is the most appropriate method to use when drawing blood from a child with hemophilia?
Show answer and rationale
Correct answer: B. Schedule all labs to be drawn at one time.
Coordinating labs to minimize sticks reduces trauma and the risk of bleeding. Finger sticks in general are more painful and associated with more bleeding than venipunctures. In hemophilia, platelets are typically normal. Heat would increase vasodilatation and increase bleeding.
A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Show answer and rationale
Correct answer: B. Sew thick padding into the elbows and knees of the child’s clothing.
As the hemophilic infant begins to acquire motor skills, the risk of bleeding increases because of falls and bumps. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant’s risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide factor replacement and:
Show answer and rationale
Correct answer: A. Institute rest, ice, compression, and elevation (RICE).
The child is displaying symptoms of bleeding in the joint and factor replacement is indicated. The RICE method is used additionally as a supportive measure to help control the bleeding. Aspirin containing compounds contribute to bleeding and should never be used to control pain. Physical therapy is instituted after the acute bleeding to prevent further damage. Orthopedic traction is considered in some rare cases during the rehabilitation phase, but not the acute phase.
Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child’s family to recognize and report which of the following?
Show answer and rationale
Correct answer: D. Yellowing of the skin.
Because factor VIII concentrate is derived from large pools of human plasma, the risk of hepatitis is always present. Clinical manifestations of hepatitis include yellowing of the skin, mucous membranes, and sclera. Use of factor VIII concentrate is not associated with constipation, abdominal distention, or puffiness around the eyes.
The mother tells the nurse she will be afraid to allow her child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which of the following activities should the nurse suggest as ideal?
Show answer and rationale
Correct answer: D. Swimming.
Swimming is an ideal activity for a child with hemophilia because it is a noncontact sport. Many noncontact sports and physical activities that do not place excessive strain on joints are also appropriate. Such activities strengthen the muscles surrounding joints and help control bleeding in these areas. Noncontact sports also enhance general mental and physical well-being. Falls and subsequent injury to the child may occur with snow skiing. Basketball is a contact sport and therefore increases the child’s risk for injury. Gymnastics is a very strenuous sport. Gymnasts frequently have muscle and joint injuries that result in bleeding episodes.
A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?
Show answer and rationale
Correct answer: C. Fever and petechiae.
Fever and petechiae associated with acute lymphocytic leukemia indicate a suppression of normal white blood cells and thrombocytes by the bone marrow and put the client at risk for other infections and bleeding. The nurse should initiate infection control and safety precautions to reduce these risks. Fatigue is a common symptom of leukemia due to red blood cell suppression. Although the client should be told about the need for rest and meal planning, such teaching is not the priority intervention. Swollen glands and lethargy may be uncomfortable but they do not require immediate intervention. An enlarged liver and spleen do require safety precautions that prevent injury to the abdomen; however, these precautions are not the priority.
A 12-year-old with leukemia is receiving cyclophosphamide. The nurse should assess for the adverse effect of:
Show answer and rationale
Correct answer: C. Cystitis.
Cystitis is a potential adverse effect of cyclophosphamide. The client should be monitored for pain on urination. Photosensitivity, ataxia, and cardiac arrhythmias are not adverse effects associated with cyclophosphamide.
After teaching the parents of a child newly diagnosed with leukemia about the disease, which of the following descriptions given by the mother best indicates that she understands the nature of leukemia?
Show answer and rationale
Correct answer: D. "The disease is a type of cancer characterized by an increase in immature white blood cells."
Leukemia is a neoplastic, or cancerous, disorder of blood-forming tissues that is characterized by a proliferation of immature white blood cells. Leukemia is not an infection, inflammation, or allergic disorder.
Which of the following is the highest risk for a child with Leukemia whose lab values are as follows: WBC 6,500 mm3 (6.5 � 109/L), platelet count 40,000 ?L (40 � 109/L), and HCT 41.2% (0.412)?
Show answer and rationale
Correct answer: D. Bleeding.
A normal platelet count is 150,000 ?L to 400,000 ?L (150 to 400 � 109/L). A platelet count of 40,000 ?L (40 � 109/L) is low and puts the child at risk for injury, bruising, and bleeding. Hematocrit of 41.2% (0.412) is normal; therefore, the child will have adequate oxygenation and tissue perfusion. 6,500 mm3 (6.5 � 109/L) is a normal white count, therefore, the child has no increase in risk for infection.
Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
Show answer and rationale
Correct answer: C. "Immature white blood cells are incapable of handling an infectious process."
In leukemia, the number of normal white blood cells that are capable of fighting an infection is decreased. Although there is an increased number of immature white blood cells, they are unable to combat infection. Therefore, a child with leukemia is subject to infection. The major morbidity and mortality factor associated with leukemia is infection resulting from the presence of granulocytopenia. While increased activity may cause fatigue, it does not put the child at risk for infection. Vitamin C intake should not decrease if the child has adequate dietary intake. Decreased red blood cells are not directly caused by infection.
Which of the following beverages should the nurse plan to give a child with leukemia to relieve nausea?
Show answer and rationale
Correct answer: B. A carbonated beverage.
Carbonated beverages ordinarily are the best tolerated when a child feels nauseated. Many children find cola drinks especially easy to tolerate, but noncola beverages are also recommended. Orange juice usually is not tolerated well because of its high acid content. Tea may also be too acidic and many children do not like tea. Water does not relieve nausea.
Which of the following medication prescriptions to help relieve discomfort in a child with leukemia should the nurse question?
Show answer and rationale
Correct answer: B. Ibuprofen.
Ibuprofen prolongs bleeding time and is contraindicated in clients with leukemia. Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen, may be prescribed to control pain and may be used in combination with codeine or hydrocodone if pain is more severe. Hydromorphone may also be used for severe pain.
After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifies which of the following as the site for the aspiration?
Show answer and rationale
Correct answer: C. Back of the hipbone.
Although bone marrow specimens may be obtained from various sites, the most commonly used site in children is the posterior iliac crest, the back of the hipbone. This area is close to the body’s surface but removed from vital organs. The area is large, so specimens can easily be obtained. For infants, the proximal tibia and the posterior iliac crest are used. The middle of the chest or sternum is the usual site for bone marrow aspiration in an adult. The wrist, chest, and thigh are not sites from which to obtain bone marrow specimens.
The nurse should instruct the client with a platelet count of 31,000/?L (31 � 109/L) to:
Show answer and rationale
Correct answer: B. Pad sharp surfaces to avoid minor trauma when walking.
A client with a platelet count of 30,000 to 50,000/?L (30 to 50 � 109/L) is susceptible to bruising with minor trauma. Padding areas that the client might bump, scratch, or hit may help prevent minor trauma. A platelet count of 15,000 to 30,000/?L (15 to 30 � 109/L) may result in spontaneous petechiae and bruising, especially on the extremities. Padding measures would still be used, but the focus would be on assessing for new spontaneous petechiae. Keeping the room dark does not help the client with a low platelet count. With a count below 20,000/?L (20 � 109/L), the client is at risk for spontaneous bleeding from the mucous membranes and intracranial bleeding.
After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child’s death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child’s imminent death?
Show answer and rationale
Correct answer: B. Relatives are especially grieved when a child does well at first but then declines rapidly.
It has been found that parents are more grieved when optimism is followed by defeat. The nurse should recognize this when planning various ways to help the parents of a dying child. It is not necessarily true that knowing about a poor prognosis for years helps prepare parents for a child’s death. Death is still a shock when it occurs. Trust in health care personnel is not necessarily destroyed when a death is untimely if the family views the personnel as having done all that was possible. It is not more difficult for parents to accept the death of an older child than that of a younger child.
A 12-year-old with leukemia will be taking vincristine. The nurse should encourage the child to eat what kind of diet?
Show answer and rationale
Correct answer: C. High-residue.
Vincristine may cause constipation, so the client should be encouraged to eat a high-residue (fiber) diet. The other diets do not help with constipation that can occur while receiving vincristine.
A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to:
Show answer and rationale
Correct answer: C. Not receive any live attenuated vaccines.
Children who are immunosuppressed should not receive any live attenuated vaccines. Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps, rubella and oral polio vaccine can develop severe forms of the diseases for which they are being immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies and it is recommended that immunizations be delayed for 3 months after the immunosuppressive drugs have been discontinued. Vitamin and mineral supplements are not normally given in conjunction with immunosuppressive drugs. When the client is immunosuppressed, the client should avoid only persons who have an infection.
A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend?
Show answer and rationale
Correct answer: B. Being treated as "normal" as much as possible.
Any child with a chronic illness should be treated as normally as possible. Unless the child has severe bone marrow depression, he should be allowed to go to school with others and can go to the mall. If the child is in remission, athletic activities are allowed.
A transfusion of packed red blood cells has been prescribed for a 1-year-old with a sickle cell anemia. The infant has a 25-gauge IV infusing dextrose with sodium and potassium. Using the situation, background, assessment, recommendation (SBAR) method of communication, the nurse contacts the primary health care provider and recommends:
Show answer and rationale
Correct answer: D. Using the existing IV, but changing the fluids to normal saline for the transfusion.
The best evidence indicates that a catheter as small as 27-gauge may safely be used for transfusion in children, but blood must be infused with normal saline, not dextrose. A 1-year-old should be able to maintain their blood glucose for the 2-hour duration of the infusion without the need for a second IV.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
Show answer and rationale
Correct answer: B. All of the above
The RN’s scope of practice includes assessment, planning, implementing, and evaluation. Only aspects of care implementation may be delegated to the LPN and the exact skills that may be delegated vary by state and institution. In general, LPNs have been trained to perform the tasks of administering oral medications, performing hygiene, and recording the intake and output. LPNs may also take vital signs to gather data, but the nurse must interpret the data. Administering IV morphine requires assessment of the client’s respiratory status before, during, and after the procedure. Circulation checks are assessments the nurses should complete.
The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse’s most important responsibility during the procedure is to:
Show answer and rationale
Correct answer: D. Monitor the client.
During conscious sedation the client may lose protective reflexes and adequate respiratory and cardiac function may be impaired. At every procedure there must be one health care professional whose sole responsibility is to monitor the client. Topical agents must be given in advance of the procedure to be effective. During the procedure, the nurse would not leave the child to speak with parents. While the procedure would be documented according to the facility’s protocols, proper monitoring of the client is the intervention most associated with reducing risks.
The nurse is transferring a child who has had open heart surgery from the intensive care unit to the pediatric unit. The child’s blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
Show answer and rationale
Correct answer: B. All of the above
The report made when nurses are "handing off" a client from one nursing unit to another must include information about the condition of the client, potential for changes in the client’s condition, current medications, and care and services received. It is not necessary to know what medications were given in surgery to provide safe care at this point.
The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child’s identity by checking the arm band and:
Show answer and rationale
Correct answer: B. Asking the parent the child’s name.
Safety standards require the use of two identifiers prior to medication administration. A parent can be used as the second identifier. Many young children will only answer to a nickname that does not coincide with the medical identification band or may answer to any name. It is common for children on a pediatric floor to go into each other’s rooms. A small child may not know their birth date.
A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first?
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Correct answer: D. Administering an emetic.
Drain cleaner almost always contains lye, which can burn the mouth, pharynx, and esophagus on ingestion. The nurse would be prepared to assist with a tracheostomy, which may be necessary because of swelling around the area of the larynx. An emetic is contraindicated because, as the substance burns on ingestion, so too would it burn when vomiting. Additionally, the mucosa becomes necrotic and vomiting could lead to perforations. Gastric lavage is contraindicated because the mucosa is burned from the ingestion of the caustic lye, causing necrosis. Gastric lavage also could lead to perforation of the necrotic mucosa. Insertion of an indwelling urinary (Foley) catheter would be indicated after the measures to remove the caustic substance have been started.
After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which of the following as a likely complication?
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Correct answer: D. Esophageal strictures.
As the burn from the lye ingestion heals, scar tissue develops and can lead to esophageal strictures, a common complication of lye ingestion. Tracheal stenosis would occur if the child had vomited and aspirated. Tracheal varices do not commonly occur after the ingestion of lye or other substances. Although very rare, esophageal diverticula may occur. Diverticula are commonly found in the colon of adults.
When developing the plan of care for a toddler who has taken an acetaminophen overdose, which of the following should the nurse expect to include as part of the initial treatment?
Show answer and rationale
Correct answer: D. Electrocardiogram.
Initial management of a child who has ingested a large amount of acetaminophen would include inducing vomiting or performing gastric lavage with or without activated charcoal to aid in the removal of the substance. Frequent blood level determinations may be obtained during the follow-up phase, but they are not done as part of the initial treatment. Tracheostomy is not typically part of the initial treatment for acetaminophen overdose. However, it may be necessary later if respiratory distress develops. Acetaminophen primarily affects the liver, not the heart. Therefore, an electrocardiogram would not be considered part of the initial treatment plan.
While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following?
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Correct answer: C. Pneumonitis.
Chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as in kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is the result of renal insufficiency, which causes nitrogenous waste products to build up in the blood rather than being excreted. Hepatitis is caused by a viral infection. Carditis in a preschooler may be the result of rheumatic fever.
Which of the following statements by the mother of an 18-month-old child should indicate to the nurse that the child needs laboratory testing for lead levels?
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Correct answer: D. "My child does not always wash after playing outside."
Eating with dirty hands, especially after playing outside, can lead to lead poisoning because lead is often present in soil surrounding homes. Also, children who eat lead-containing paint chips commonly develop lead poisoning. Drinking two cups of milk per day is less than that which is recommended for this age group, so more nutritional information would need to be obtained. Temper tantrums are characteristic of 18-month-old children as they try to assert themselves. Determining whether the child is smaller than other children the same age requires measuring height and weight and plotting them on growth charts. In addition, inadequate growth could be a result of numerous causes, such as genetics, chronic illness, or chronic drug use (eg, prednisone).
In an initial screening for lead poisoning, a 2-year-old child is found to have a lead level of 10 mcg/dL (0.48 ?mol/L). The nurse should:
Show answer and rationale
Correct answer: A. Educate parents on ways to reduce lead in the environment.
Treatment for children with minimally elevated lead levels should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach 45 mcg/dL (2.2 ?mol/L). There is no such thing as a "normal" lead level because there is no beneficial action in the body.
When teaching the mother of a toddler diagnosed with lead poisoning, which of the following should the nurse include as the most serious complication if the condition goes untreated?
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Correct answer: B. Neurologic deficits.
The most serious and irreversible consequence of lead poisoning is mental retardation due to neurologic changes. It can be expected if lead poisoning is long-standing and goes untreated. Lead poisoning also affects the hematologic and renal systems. Cirrhosis is the end stage of several chronic liver diseases, such as biliary atresia and hepatitis. Lead poisoning is not associated with stunted growth. Chronic illnesses, such as cystic fibrosis, cause slowing of the growth velocity. Heart failure is associated with congenital heart disease and rheumatic fever.
The nurse is teaching dietary interventions to the parents of a child with an elevated blood lead level (EBLL). Which nutrient is least important to include in the child’s diet?
Show answer and rationale
Correct answer: C. Vitamin A.
Vitamin A is not known to play a significant role in preventing EBLL. Calcium intake inhibits lead absorption. Children with EBLL levels often are anemic. While this relationship is not well understood, iron supplementation has been shown to improve developmental outcomes. Vitamin C improves iron absorption.
During assessment of a child with celiac disease, the nurse should most likely note which of the following physical findings?
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Correct answer: B. Protuberant abdomen.
The intestines of a child with celiac disease fill with accumulated undigested food and flatus, causing the characteristic protuberant abdomen. Celiac disease is not usually associated with any liver dysfunction, including poor liver functioning leading to liver enlargement. Tender inguinal lymph nodes are often associated with an infection. Periorbital edema, swelling around the eyes, is associated with nephritis.
After teaching the mother of a child with celiac disease about dietary management, which of the following statements by the mother indicates successful teaching?
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Correct answer: B. "I will plan to feed my child foods that contain rice."
Damage to intestinal mucosa in celiac disease is caused by gliadin, a part of the protein found in wheat, rye, barley, and oats. Foods containing these grains must be eliminated entirely from the diet of children with celiac disease. Foods containing rice and corn are a good substitute. Although an adequate intake of milk is important for any child, children with celiac disease do not need an increased milk intake.
After teaching the parents of a child with celiac disease about diet, which of the following, if stated by the parents to be avoided, indicates effective teaching?
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Correct answer: B. All of the above
Children with celiac disease should avoid foods containing the protein gluten, which is found in wheat, oats, rye, and barley grains. Children are allowed to eat foods containing rice or corn. Labels need to be read carefully since these glutens are used as fillers in many food items including many types of chocolate candy and hot dogs.
Which of the following foods would be appropriate for a 12-month-old child with celiac disease?
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Correct answer: D. Rice cereal.
The child with celiac disease should not eat foods containing wheat, oats, rye, or barley. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided. Foods containing rice, such as rice cereal, or corn are appropriate. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided.
The mother of a child with celiac disease asks, "How long must he stay on this diet?" Which response by the nurse is best?
Show answer and rationale
Correct answer: D. "For the rest of his life."
Most children with celiac disease have a lifelong sensitivity to gluten, which requires that they maintain some type of diet restriction for the rest of their lives.
When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results?
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Correct answer: C. Initial formula or breast milk at least 24 hours before the test.
PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid, phenylalanine, to tyrosine. To ensure reliable results, the neonate must have ingested sufficient protein, such as breast milk or formula, for at least 24 hours. Testing the infant before that time, excessive vomiting, or poor intake can yield false-negative results. The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.
When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which of the following goals?
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Correct answer: C. Meeting the child’s nutritional needs for optimal growth.
The goal of care is to prevent mental retardation by adjusting the diet to meet the infant’s nutritional needs for optimal growth. The diet needs to be started upon diagnosed, ideally within a few days of birth. Serum phenylalanine level should be maintained between 3 and 7 mg/100 mL (180 to 420 ?mol/L). Significant brain damage usually occurs if the level exceeds 10 to 15 mg/100 mL (600 to 900 ?mol/L). If the level drops below 2 mg/100 mL (120 ?mol/L), the body begins to catabolize its protein stores, causing growth retardation.
When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of which of the following foods should cause the nurse to gather additional information?
Show answer and rationale
Correct answer: A. Cola.
Foods with low phenylalanine levels include vegetables, fruits, and juices. Foods high in phenylalanine include meats and dairy products, which must be restricted or eliminated. Colas contain more phenylalanine than the fruits listed.
Which foods would the nurse teach the parents of a child with phenylketonuria (PKU) to avoid?
Show answer and rationale
Correct answer: C. All of the above
Children with PKU lack an enzyme to metabolize phenylalanine and convert it to tyrosine. Treatment is dietary management to control the amount of phenylalanine ingested. Foods with low phenylalanine levels include fruits, most vegetables, and cereals. High-protein foods have high levels of phenylalanine and include meats and dairy products.
When teaching the mother of a child diagnosed with phenylketonuria (PKU) about its transmission, the nurse should use knowledge of which of the following as the basis for the discussion?
Show answer and rationale
Correct answer: B. Autosomal recessive gene.
PKU is caused by an inborn error of metabolism. It is an autosomal recessive disorder that inhibits the conversion of phenylalanine to tyrosine. A form of Down syndrome, trisomy 21, is an example of a disorder caused by chromosomal translocation. Cri du chat is an example of a disorder caused by chromosomal deletion. Hemophilia A is an example of a disorder caused by an X-linked recessive gene.
A newborn diagnosed with phenylketonuria (PKU) is placed on a milk substitute, Lofenalac. The mother asks the nurse how long her infant will be taking this. Which of the following responses would be most appropriate?
Show answer and rationale
Correct answer: D. "Probably for a long time, but it’s not definitely known."
Although it is not known how long diet therapy must continue for children with PKU, many experts suggest continuing it indefinitely because of academic difficulties and lower intelligence quotients in older children who have stopped the restrictive diet. For women, it is necessary to resume the diet before conception to lower the phenylalanine levels in the fetus and prevent complications.
Even though several teaching sessions have been documented in the client’s health record, the mother asks the nurse again what caused her child’s phenylketonuria (PKU). Which of the following statements would best reflect the nurse’s interpretation of why the mother keeps asking for information that she has already received?
Show answer and rationale
Correct answer: C. Parents of a chronically ill child commonly require a long time to work through the grieving process for their child’s disease.
PKU is considered a chronic illness. Parents typically grieve about the loss of health in their child afflicted with a chronic disease. Many times, they repeat questions, as though trying to deny what is really happening. This type of behavior represents an attempt to integrate the experience and their feelings with their self-image as they pass through the grieving process. Asking for detailed explanations, testing the competence of health workers, and expressing impatience with health workers may explain the parents’ behavior, but viewing the behavior as a part of the grieving process is the most plausible explanation.
When performing the nursing history, which of the following would be most important for the nurse to obtain from the mother of an infant with suspected colic?
Show answer and rationale
Correct answer: D. The infant’s crying pattern.
Information on the crying pattern of the infant is most helpful in confirming the diagnosis of colic. Typically the colic attack begins abruptly, with the infant crying loudly and continuously, possibly for hours. The attack may end when the child becomes exhausted. The child also may attain some relief after passing stool or flatus. Often, in an attempt to alleviate the infant’s crying, parents try to feed the infant, resulting in overfeeding leading to discomfort and distention. Asking about the type of formula, sleep position, or position for burping will not provide sufficient information to confirm the diagnosis of colic. However, the nurse can obtain additional information after determining the nature of the crying pattern.
The parents of a child with colic are asked to describe the infant’s bowel movements. Which of the following descriptions should the nurse expect?
Show answer and rationale
Correct answer: C. Soft, yellow stools.
Infants with colic usually pass normal stools, typically soft and yellowish. Frequent watery stools might indicate diarrhea. Ribbon-like stools are suggestive of a narrowing of the colon or the rectum. Foul-smelling stools by themselves are related to diet. When other symptoms such as large size and protuberant abdomen are present, malabsorption may be possible.
The mother tells the nurse that the diagnosis of colic upsets her because she knows her infant will continue to have colicky pain. Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: A. "It can be difficult to listen to your baby cry so loud and so long, so try to make sure that you get some free time."
The nurse needs to provide the parents with support because of the infant’s crying. The parents are stressed and need to be encouraged to get out of the house and arrange for some free time. Although infants need lots of attention and care for the first few months, they do not need the mother’s undivided attention. Comparing colic with other problems is inappropriate. Parents have the right to be upset. Although colic usually disappears spontaneously by age 3 months, the nurse should not make any guarantees.
The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which of the following?
Show answer and rationale
Correct answer: C. Burping the infant during and after the feeding.
Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the mother’s shoulder so that the infant’s abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant’s abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.
An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should:
Show answer and rationale
Correct answer: D. Refer the family to a dietician.
Children aged 2 to 20 years with a BMI-for-age at the 90th percentile are considered overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child’s weight gain until an appropriate height for weight is attained. Without intervention, the child may become obese. A health care provider who specializes in pediatric weight loss should be considered when the child is obese and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate.
When counseling an obese adolescent, the nurse should advise the client that which complication is the most common?
Show answer and rationale
Correct answer: D. Lifelong obesity.
The most common complication of adolescent obesity is its persistence into adulthood. The incidence of gastrointestinal and orthopedic problems, such as Legg-Calv�-Perthes disease and genu valgum (knock knees), is greater for obese adolescents; however, they are not the most common complication. Although psychosocial problems do occur, they are not the most common complication.
Weight loss has been recommended for an overweight adolescent at a rate of approximately . The nurse explains this can be done by increasing activity and reducing empty calories by how many calories per day? ___________________ cal/day.
Show answer and rationale
Correct answer: B. 250 cal/day
250 cal/day. To lose 1 lb of weight, a client needs to burn approximately 3,500 cal. 0.5 lb � 3,500 cal/lb � 7 days = 250 cal/day.
After teaching the parents of a child with lactose intolerance about the disorder, the nurse determines that the teaching was effective when the mother describe the condition?
Show answer and rationale
Correct answer: A. "The lack of an enzyme to break down lactose."
Lactose intolerance is not an allergy. Rather, it is caused by the lack of the digestive enzyme lactase. This enzyme, found in the intestines, is necessary for the digestion of lactose, the primary carbohydrate in cow’s milk. Protein and fat digestion are not affected.
After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child’s diet, which of the following if stated by the mother indicates effective teaching?
Show answer and rationale
Correct answer: A. Cheese.
People who are lactose-intolerant usually are able to tolerate dairy products in which lactose has been fermented, such as yogurt, cheese, and buttermilk. Pudding, ice cream, and creamed soups contain lactose that has not been fermented.
The breast-feeding mother of a 1-month-old diagnosed with cow’s milk sensitivity asks the nurse what she should do about feeding her infant. Which of the following recommendations would be most appropriate?
Show answer and rationale
Correct answer: D. Continue to breast-feed but eliminate all milk products from your own diet.
Mothers of infants with a cow’s milk allergy can continue to breast-feed if they eliminate cow’s milk from their diet. It is important to encourage mothers to continue to breast-feed because breast milk is usually the least allergenic and most easily digested food for an infant. In addition, the infant is able to obtain protein through the mother’s milk. If the mother stops breast-feeding, then a predigested protein hydrolysate formula would be the first choice. An iron-fortified formula is a cow’s milk-based formula. A soy-based formula is not used because approximately 20% of infants with cow’s milk sensitivity are also sensitive to soy. Solid foods are not introduced until the infant is 4 to 6 months of age.
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which of the following would be the most effective method of follow-up?
Show answer and rationale
Correct answer: D. Weekly visits by a community health nurse.
most effective follow-up care would occur in the home environment. The community health nurse can be supportive of the parents and will be able to observe parent-infant interactions in a natural environment. The community health nurse can evaluate the infant’s progress in gaining weight, offer suggestions to the parents, and help the family solve problems as they arise.
When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
Show answer and rationale
Correct answer: D. Verify that the gastric PH is less than 5.5.
For children receiving intermittent gavage feedings, the best method to verify the tube placement before each feeding is to aspirate a small amount of gastric contents to verify that the pH is acidic. A pH of 5.5 or less should indicate correct placement in most babies. Depending on the type of feeding tube used, an x-ray may be used to confirm the original tube placement, but use before every feeding would expose the child to unnecessary radiation. Air boluses are misleading because placement in the esophagus or respiratory tract may make the same sound in small infants. Charts might be helpful in determining initial tube insertion length, but do not substitute for nursing assessments.
A child with a nut allergy is admitted with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." The nurse should first:
Show answer and rationale
Correct answer: B. Assess the parent’s ability to read.
Three severe reactions in 3 months indicate a serious problem with adhering to the prevention plan. The nurse should first determine if the parent can actually read the label. The underlying problem may be that the parent is visually impaired or unable to read. The parent’s reading level determines what additional support is needed. Referrals to social service or dietary may be indicated, but the nurse does not yet have enough information about the problem. The nurse would communicate with the primary care provider after assessing the situation to recommend referrals.
When developing the plan of care for an infant with a cleft lip before corrective surgery is performed, which of the following should be a priority?
Show answer and rationale
Correct answer: C. Altering the usual method of feeding.
Before corrective surgery for a cleft lip, the infant needs to consume formula or breast milk. Methods for feeding may need to be adjusted to fit the infant’s needs, because the infant with a cleft lip experiences a decreased ability to suck, which interferes with the infant’s ability to compress the nipple. A special feeder may be used to feed the infant to ensure adequate caloric intake. Problems with infection and skin integrity in the mouth are uncommon because the areas of the defect are not open areas. Although crying may cause the infant to swallow more air because of the defect, crying poses no harm to the infant. There is no need to keep the infant’s fingers out of the mouth preoperatively. The fingers will not harm the defect or cause an infection.
Which of the following measures would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?
Show answer and rationale
Correct answer: A. Burp the infant at frequent intervals.
An infant with a cleft lip and palate typically swallows large amounts of air while being fed and therefore should be burped frequently. The soft palate defect allows air to be drawn into the pharynx with each swallow of formula. The stomach becomes distended with air, and regurgitation, possibly with aspiration, is likely if the infant is not burped frequently. Feeding frequently, even in small amounts, would not prevent swallowing of large amounts of air. A nipple placed in the back of the mouth is likely to cause the infant to gag and aspirate. Holding the infant in a lying position during feedings can also lead to regurgitation and aspiration of formula. The infant should be fed in an upright position.
After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent states which of the following?
Show answer and rationale
Correct answer: D. "We will keep the restraints on continuously except when checking the skin under them for redness."
To keep the infant from disturbing the suture line by placing fingers or other objects in the mouth, either intentionally or accidentally, the restraints should be in place at all times. They should be removed for a short period, however, so that the underlying skin can be checked for any redness or breakdown. While the restraints are removed, the parents should be instructed to manually restrain the hands and arms.
The parent of an infant with a cleft lip and palate asks the nurse when the infant’s cleft palate will be repaired. The nurse responds by stating that the first repair of a cleft palate is usually done at which of the following times?
Show answer and rationale
Correct answer: C. After the child learns to drink from a cup.
The optimal time for cleft palate repair depends on many factors. However, it is best done before speech develops and the child learns faulty speech habits as a result of the defect, usually before 12 to 15 months of age. Tooth eruption usually begins at about 6 months of age. The child should weigh about 10 kg (22 lb) at 6 months, but the important consideration is to schedule surgery before speech patterns begin to develop. An infant may learn to start drinking from a cup as early as 6 to 7 months of age, possibly up to the first birthday.
The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the primary care provided to further assess the baby and request a prescription for:
Show answer and rationale
Correct answer: D. An x-ray with orogastric catheter placement.
The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when an orogastric catheter cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.
The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby’s anomaly. Which of the following approaches by the nurse would best support the parents?
Show answer and rationale
Correct answer: B. Helping the parents accept their feelings as a normal reaction.
The parents of children born with defects often have feelings of guilt and ask what they might have done to cause the condition or how they might have avoided it. It is important to allow parents to express their feelings and to accept these feelings as normal reactions. Explaining that the parents are not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging long-term planning generally is of little benefit to parents who are emotionally distraught. Additionally, the parents may interpret this as ignoring their feelings and confirming that they played a role in causing their child’s anomaly. Urging the parents to visit their infant as often as possible would generally be of little help and could appear to the parents as though they are being "talked out" of their feelings.
After teaching the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the father describes the condition as which of the following?
Show answer and rationale
Correct answer: C. "There is a blind upper pouch and an opening from the esophagus into the airway."
Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.
Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?
Show answer and rationale
Correct answer: A. Substernal retractions.
With a TEF, overflow of secretions into the larynx leads to laryngospasm. This obstruction to inspiration stimulates the strong contraction of accessory muscles of the thorax to assist the diaphragm in breathing. This produces substernal retractions. The laryngospasm that occurs with a TEF resolves quickly when secretions are removed from the oropharynx area. A brassy cough is related to a relatively constant laryngeal narrowing, usually caused by edema. It is not an indication of the need to suction. A decreased activity level and an increased respiratory rate in an infant with a TEF are usually the result of hypoxia, a relatively long-term and constant phenomenon in infants with a TEF.
The nurse is administering gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). To prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube the nurse should:
Show answer and rationale
Correct answer: B. Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel.
The best way to prevent air from entering the stomach when feeding an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous flow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach.
After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. After feeding the infant by this method, the nurse cradles and rocks the infant for about 15 minutes, primarily to help accomplish which of the following?
Show answer and rationale
Correct answer: C. Associate eating with a pleasurable experience.
The nurse can help meet the psychological needs of an infant being fed through a gastrostomy tube by rocking the infant after a feeding. The infant soon learns to associate eating with a pleasurable experience and learns to trust the caregiver. Rocking the infant will not promote peristalsis or prevent regurgitation. Holding the baby will not relieve pressure on the surgical site. However, holding the child right after feeding promotes comfort and pleasure.
A newborn who had a surgical repair of a tracheoesophageal fistula (TEF) is started on oral feedings. Which of the following should the nurse include in the teaching plan for the mother about oral feedings?
Show answer and rationale
Correct answer: A. They are best planned in conjunction with observations of the infant’s behavior.
When initiating oral feedings after surgical repair of a TEF, it is best to follow a plan of care in conjunction with observation of the infant’s needs and behavior. When the infant’s needs and behavior are overlooked, plans are likely to be unsatisfactory and are more likely to meet the nurse’s needs rather than the infant’s needs. After a surgical procedure, infants initially tolerate small amounts of fluids offered more frequently better than larger amounts offered less often. Smaller amounts cause less bloating as the infant becomes used to feeding again. Although infants accept feedings more readily from their mother or from someone who feeds the infant repeatedly, the priority is to meet the infant’s nutritional needs based on the infant’s behavior.
After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant’s parents are Catholic and do not want the surgery to take place unless the infant has first been baptized. The nurse asks the parents:
Show answer and rationale
Correct answer: B. "Do you want me to help arrange the baptism?"
The nurse should honor the parent’s belief system and help arrange to have the infant baptized. This may be done through the hospital’s chaplaincy department or by the family’s clergy. The parents may indeed be worried that the infant may die during surgery. Having the infant baptized would help address the family’s spiritual needs. At this time there is an immediate need for chaplaincy, not social service. While surgery may be postponed briefly, the infant cannot begin feeding until an outlet for stool as been established. Therefore, it is not advisable to postpone the surgery for a prolonged period of time.
Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation?
Show answer and rationale
Correct answer: B. All of the above
After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant’s parents are Catholic and do not want the surgery to take place unless the infant has first been baptized. The nurse asks the parents:
After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child’s prognosis when she states which of the following?
Show answer and rationale
Correct answer: C. "My child has a good chance of being potty trained."
Children who undergo surgical correction for low anorectal anomalies as infants usually are continent. Fecal continence can be expected after successful correction of anal membrane atresia. Therefore, this child probably has a good chance of being potty trained and will not need to wear protective pads. Extra fluids and a high-fiber diet are not required to prevent constipation. Children with high anorectal anomalies may or may not achieve continence.
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse’s best response?
Show answer and rationale
Correct answer: A. "Newborns typically move their whole body in response to pain."
The neonate responds to pain with total body movement and brief, loud crying that ceases with distraction. After the age of 6 months, an infant reacts to pain with intense physical resistance and tries to escape by rolling away. A toddler reacts to pain by withdrawing the affected part.
When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, which of the following would be most helpful in facilitating parent-infant bonding?
Show answer and rationale
Correct answer: B. Encouraging the parents to hold their infant.
Encouraging the parents to hold their neonate promotes parent-infant attachment. Parent-infant bonding is based on a relationship that begins when the parent first touches the infant. Both the parents and the infant have predictable steps that they go through in this process. Explaining that the parents can visit at any time promotes bonding only if they do visit with, talk to, and hold the newborn. Asking the parents to help monitor intake and output at this time may be too anxiety-producing, thus interfering with bonding. Helping the parents plan for the infant’s discharge involves them in the newborn’s care and is important. However, it is not the first step in the development of bonding.
A 4-week-old infant admitted with the diagnosis of hypertrophic pyloric stenosis presents with a history of vomiting. The nurse should anticipate that the infant’s vomitus would contain gastric contents and which of the following?
Show answer and rationale
Correct answer: D. Mucus and streaks of blood.
The vomitus of an infant with hypertrophic pyloric stenosis contains gastric contents, mucus, and streaks of blood. The vomitus does not contain bile or stool because the pyloric constriction is proximal to the ampulla of Vater.
After teaching the mother of an infant with pyloric stenosis about the disease, which of the following, if stated by the mother as a cause, indicates effective teaching?
Show answer and rationale
Correct answer: B. "An enlarged muscle below the stomach sphincter."
Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding too quickly, or underfeeding is not associated with pyloric stenosis.
A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has prescribed IV fluids of dextrose water with sodium and potassium. The baby’s admission potassium level is 3.4 mEq/L (3.4 mmol/L). The nurse should:
Show answer and rationale
Correct answer: C. Verify that the infant has urinated.
Normal serum potassium levels are 3.5 to 4.5 mEq/L (3.5 to 4.5 mmol/L). Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4 mEq/L (3.4 mmol/L) is not unexpected and should be corrected with the prescribed fluids. The lab value does not need to be redrawn as the findings are consistent with the infant’s condition.
After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in stable condition. While standing by the crib, the mother says, "Perhaps if I had brought my baby to the hospital sooner, the surgery could have been avoided." Which of the following should be the nurse’s best response?
Show answer and rationale
Correct answer: D. "Do you think that earlier hospitalization could have avoided surgery?"
Restating or rephrasing a mother’s response provides the opportunity for clarification and validation. It also helps to focus on what the mother is saying and address her concerns and feelings. Although surgery is the most effective treatment for pyloric stenosis, stating this ignores the mother’s feelings and does not give her an opportunity to express them. Telling the mother not to worry also ignores the mother’s feelings. Additionally, this type of statement gives the mother premature reassurance, which may turn out to be false. Asking the mother if she thinks the problem indicates that she is not a good mother implies such an idea. It does not allow her to express her concerns and feelings and therefore is not a therapeutic response.
After surgery to correct pyloric stenosis, the nurse instructs the parents about the postoperative feeding schedule for their infant. The parents exhibit understanding of these instructions when they state that they can start feeding the child within which of the following time frames?
Show answer and rationale
Correct answer: B. 6 hours.
Clear liquids containing glucose and electrolytes are usually prescribed 4 to 6 hours after surgery. If vomiting does not occur, formula or breast milk then can be gradually substituted for clear liquids until the infant is taking normal feedings.
Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. Which of the following actions would be most appropriate at this time?
Show answer and rationale
Correct answer: A. Give the infant a pacifier to suck on.
Giving the infant a pacifier would help meet nonnutritive sucking needs and ensure oral gratification. Additionally, sucking aids in calming the infant. Holding the infant to decrease fussiness and restlessness is more effective in an older infant. Also, the reason for the infant’s fussiness needs to be explored. Hanging a mobile over the crib frequently does not decrease fussiness. After surgery to correct pyloric stenosis, feeding the infant more formula would lead to vomiting, putting additional stress on the operative site.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant’s crying and episodes of pain?
Show answer and rationale
Correct answer: C. Intermittent with knees drawn to the chest.
The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the mother’s arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.
When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful?
Show answer and rationale
Correct answer: D. "What do the stools look like?"
For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception.
A nasogastric tube inserted during surgery to correct an infant’s intussusception is no longer freely removing gastric secretions. Which of the following should the nurse do next?
Show answer and rationale
Correct answer: A. Aspirate the tube with a syringe.
The first action is to check the placement of the tube to ensure that it is in the correct position. To check tube position, the nurse should aspirate the tube with a syringe. A return of gastric contents indicates that the end of the tube is in the stomach. Another method is to inject a small amount of air while auscultating with a stethoscope over the epigastric area. The tube is irrigated with normal saline, not distilled water, and only after the position of the tube is confirmed. The suction level should not be increased, because doing so could damage the mucosa. Rotating the tube could irritate or traumatize the nasal mucosa.
Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
Show answer and rationale
Correct answer: A. Auscultation of bowel sounds.
Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother:
Show answer and rationale
Correct answer: B. The infant will experience a change in the normal home routine.
Infants who have had an interruption in their normal routine and experiences, such as hospitalization and surgery, typically manifest behavior changes when discharged. The infant’s normal routine has been significantly altered, so it will take time to reestablish another routine. Calorie requirements at home will continue to be the same as those in the hospital. The infant does not need more calories at home. The surgical procedure corrected the problems, so the infant should not continue to have abdominal cramping.
When assessing an infant with suspected inguinal hernia, which of the following findings would be most significant?
Show answer and rationale
Correct answer: A. The inguinal swelling is reddened, and the abdomen is distended.
Abdominal distention and a redness of the inguinal swelling are significant findings. Their presence in conjunction with area tenderness and inability to reduce the hernia indicate an incarcerated hernia. An incarcerated hernia can lead to strangulation, necrosis, and gangrene of the bowel. Other findings associated with strangulation include irritability, anorexia, and difficulty in defecation. Irritability is nonspecific and could be caused by various factors. A palpable, thickened spermatic cord on the affected side is diagnostic of inguinal hernia and would be an expected finding. A wet diaper indicates that urine is being excreted, a finding unrelated to inguinal hernia.
The primary care provider is able to reduce an infant’s hernia and schedules the infant for a herniorrhaphy in 2 days. The mother asks the nurse why the surgery is not performed now. Which of the following responses indicates that the nurse understands the rationale for delaying the surgery?
Show answer and rationale
Correct answer: C. "Waiting these 2 days helps to allow any edema and inflammation in the area to subside."
If nonoperative reduction is successful, delaying surgery for 2 to 3 days allows the edema and inflammation in the inguinal area to subside. Thus, the area to be operated will appear more normal, helping to decrease the risk of complications. The preoperative preparation for a herniorrhaphy is minimal and is not the reason for delaying the surgery. Typically, the infant is fed until a few hours before surgery to prevent dehydration. Trusses do not prevent incarceration, and there is no reason to use a truss preoperatively.
Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal?
Show answer and rationale
Correct answer: D. Having the mother stay with the infant.
The best way to prepare a 7-month-old infant psychologically for surgery is to have the primary caretaker stay with the child. Infants in the second 6 months of life commonly develop separation anxiety. Therefore, the priority in this case is to support the child by having the parent present. Teaching the mother what to expect may decrease her anxiety; this is important because infants sense anxiety and distress in parents, but the priority in this case is to have the parent present. Actual play and acting out life experiences are appropriate for preschool-age children. Allowing an infant to play with surgical equipment would be inappropriate and dangerous.
Which of the following instructions should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?
Show answer and rationale
Correct answer: C. Change diapers as soon as they become soiled.
Changing a diaper as soon as it becomes soiled helps prevent wound infection, the most common complication after inguinal hernia repair in an infant secondary to possible wound contamination with urine and stool. Because the surgical wound is unlikely to separate, an abdominal binder is unnecessary. The incision may or may not be covered with a dressing. If a dressing is not used, the primary care provider may apply a topical spray to protect the wound. Restraining the infant’s hands is unnecessary if the diaper is applied snugly. The infant would be unable to get the hands into the diaper close to the surgical site.
A mother asks, "How should I bathe my baby now that he’s had surgery for his inguinal hernia?" Which of the following instructions should the nurse give the mother?
Show answer and rationale
Correct answer: C. "Give him a sponge bath daily for 1 week."
The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. Cleaning the infant’s face and diaper area should occur at least daily and continuously, not limited to a 2-week period. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate.
A male adolescent who underwent repair of an inguinal hernia earlier today and is getting ready to go home receives instructions about resuming physical activities. Which of the following statements would indicate that he has understood the instructions?
Show answer and rationale
Correct answer: C. "I can start wrestling again in 3 weeks."
Because of possible stress on the suture line, physical activities such as bicycle riding, physical education classes, weight lifting, and wrestling are contraindicated for about 3 weeks.
During physical assessment of a 4-month-old infant with Hirschsprung’s disease, the nurse should most likely note which of the following?
Show answer and rationale
Correct answer: D. Weight less than expected for height and age.
Infants with Hirschsprung’s disease typically display failure to thrive, with poor weight gain due to malabsorption of nutrients. Therefore, the nurse would expect to see a child who weighs less than that which is expected for height and age. A distended, rather than a scaphoid-shaped, abdomen would be noted. Cyanosis of fingers and toes is associated with congenital heart disease. Hyperactive deep tendon reflexes are associated with upper motor neuron problems, such as cerebral palsy.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
More NCLEX practice and review
Everything on this site tagged NCLEX lives in the NCLEX category.
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