during a well baby check of a 6 month old infant the nurse notes abrasions and petechaie of the palate the nurse should
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

2. The primary organ for drug elimination is the:

Correct answer: C

Rationale: The correct answer is the kidney(s) because most drugs are excreted in the urine, either as the parent compound or as drug metabolites. The skin is not the primary organ for drug elimination; only a few drugs are excreted in sweat. The lung(s) primarily excrete volatile gases with expiration, not drugs. While the liver metabolizes drugs, it is the kidney(s) that primarily eliminate drugs through urine, especially those with a molecular weight above 300.

3. A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?

Correct answer: C

Rationale: Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.

4. An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?

Correct answer: D

Rationale: One of the significant barriers for elderly clients to admit being victims of abuse is the fear of reprisal or further violence if the incident is reported. Elderly individuals may be afraid of the consequences of reporting abuse, such as retaliation or increased violence from the abuser. This fear can prevent them from disclosing their victimization. Choices A and C are incorrect as knowledge of the rarity of elder abuse and the availability of appropriate screening tools do not directly impact the client's willingness to admit abuse. Choice B, personal belief that abuse is deserved, may be a factor for some individuals but is not as common or impactful as the fear of reprisal or further violence.

5. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

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