NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate?
- A. Normally, the testes descend by one year of age.
- B. The infant will likely require surgical intervention.
- C. The infant likely has only one testis.
- D. Normally, the testes are descended by birth.
Correct answer: A
Rationale: The correct answer is that normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. The exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. Option B is incorrect as not all cases of undescended testes require surgical intervention. Option C is incorrect because feeling only one testis does not necessarily mean the infant only has one testis. Option D is inaccurate as the testes do not normally descend by birth, but rather by one year of age. If the testes do not descend by one year, a full assessment will be needed to determine the appropriate treatment.
2. Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?
- A. Contractures.
- B. Constipation.
- C. Calcium loss.
- D. Catabolism.
Correct answer: C
Rationale: All choices are hazards of immobility, but only calcium loss from the bones is a skeletal system impairment that results from immobility. Contractures are muscle shortening due to prolonged positioning, which affects the muscular system. Constipation is a gastrointestinal issue. Catabolism is a metabolic process, not specific to the skeletal system.
3. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?
- A. I'm going to help you lie lat on your back for this."
- B. Don't worry, I'm sure everything will be all right."
- C. I will need to help you remove your shirt for this procedure."
- D. Now that the procedure is inished, I will put a small bandage over the puncture site."
Correct answer: D
Rationale: An amniocentesis is performed to draw amniotic luid from the sac around the fetus during pregnancy. It may be analyzed for certain disorders or complications associated with pregnancy. Following the procedure, the nurse should wash the client's abdomen and place a small bandage over the puncture site
4. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?
- A. Administer hypotonic solutions
- B. Keep the head of the bed elevated
- C. Increase the client's core body temperature to 99.9 degrees
- D. Administer corticosteroids as ordered
Correct answer: D
Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.
5. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
- A. The client is an emancipated minor
- B. The mother has to work and is unavailable
- C. The client has a job and a driver's license
- D. The mother does not speak English
Correct answer: A
Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.
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