the nurse has been assigned to care for a neonate just delivered who has gastroschisis which concern should the nurse address in the clients plan of c
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NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care?

Correct answer: A

Rationale: In a neonate with gastroschisis, the bowel herniates through a defect in the abdominal wall without a covering membrane, which puts the neonate at high risk of infection. Immediate surgical repair is necessary due to the vulnerability of the exposed bowel to infection. Therefore, the most critical concern for the nurse to address in the plan of care of a neonate with gastroschisis is preventing infection. Poor body image is not a priority in neonatal care as neonates do not have body image concerns. Decreased urinary elimination is not typically a direct consequence of gastroschisis as it primarily affects the gastrointestinal system, not the genitourinary system. Cracking oral mucous membranes are not relevant to gastroschisis as it involves the lower gastrointestinal system, not the oral cavity.

2. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?

Correct answer: A

Rationale: When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.

3. The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?

Correct answer: A

Rationale: Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined, but rather acquired through social interactions. The correct answer, 'Learned through language acquisition and socialization,' aligns with the understanding that culture is a learned behavior. Choices B, C, and D are incorrect because culture is not genetically determined, nonspecific, or biologically based on physical characteristics. Understanding that culture is acquired through language and socialization is essential for healthcare providers to provide culturally competent care.

4. The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?

Correct answer: C

Rationale: Guilt is a common reaction of parents when their child is diagnosed with glomerulonephritis. Parents often blame themselves for not responding promptly to the child's initial symptoms or feel guilty for not seeking treatment sooner, thinking they could have prevented the development of glomerular damage. While fear of a complicated treatment regimen, anger at the child for hospitalization, and depression about the child not playing sports may be valid concerns, they are generally not as commonly observed as the feeling of guilt among parents in this situation.

5. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

Correct answer: C

Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.

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