the mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed which is the most appropriate response by the nurs the mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed which is the most appropriate response by the nurs
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NCLEX RN Exam Review Answers

1. The mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed. Which is the most appropriate response by the nurse?

Correct answer: Circumcision has been delayed to save tissue for surgical repair.

Rationale: The reason circumcision is not performed in a newborn with hypospadias is that the dorsal foreskin tissue will be needed for the surgical repair of hypospadias. Delaying circumcision allows for the preservation of tissue that will be crucial for the corrective surgery. This surgical repair is typically done within the first year of life to minimize the psychological impact on the child. Choices A, B, and C are incorrect as they do not address the specific reason for delaying circumcision in this case.

2. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

Correct answer: Send him to the emergency room for evaluation

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

3. The patient with chronic pancreatitis will be taught to take the prescribed pancrelipase (Viokase)

Correct answer: with each meal.

Rationale: The correct answer is to take pancrelipase (Viokase) with each meal. Pancrelipase is a pancreatic enzyme replacement medication that helps with the digestion of nutrients. Patients with chronic pancreatitis often have difficulty digesting food properly due to insufficient pancreatic enzyme production. Taking pancrelipase with each meal assists in the breakdown of fats, proteins, and carbohydrates consumed during the meal. Option A ('at bedtime') is incorrect because enzymes should be taken with meals to aid in digestion. Option B ('in the morning') is not ideal as it does not ensure optimal enzyme activity during meals. Option D ('for abdominal pain') is incorrect as pancrelipase is not meant to be taken solely for pain relief but rather to aid in digestion.

4. In the care of a withdrawn, reclusive psychotic client, which goal is the priority?

Correct answer: A: Establish trust

Rationale: The priority goal in the care of a withdrawn, reclusive psychotic client is to establish trust. Trust is fundamental in building a therapeutic relationship, which is essential for effective care. Without trust, the client may not engage in therapy or interventions. Once trust is established, the nurse can then assess the client's feelings of self-worth, sense of identity, and ability to socialize. While these other goals are important in the overall care of the client, establishing trust forms the foundation for further progress in the therapeutic relationship and treatment.

5. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

Correct answer: D: Fractured wrists

Rationale: The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.

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