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NCLEX RN Exam Review Answers

1. Which of the following clients have barriers to accessing healthcare?

Correct answer: All of the above

Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.

2. A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?

Correct answer: Polyuria

Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.

3. You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?

Correct answer: The infant had doubled their birth weight at twelve months.

Rationale: The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age. The mother’s reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight. As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.

4. As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?

Correct answer: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.

Rationale: You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.

5. The healthcare professional needs to validate which of the following statements pertaining to an assigned client?

Correct answer: The client reported an infected toe.

Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.

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