the nurse is caring for a newborn infant after surgical intervention for imperforate anus the nurse should place the infant in which position in the p

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. The nurse is caring for a newborn infant after surgical intervention for imperforate anus. The nurse should place the infant in which position in the postoperative period?

A. Supine with no head elevation
B. Side-lying with the legs flexed
C. Side-lying with the legs extended
D. Supine with the head elevated 30 degrees

Correct answer: B

Rationale: After surgical intervention for imperforate anus, the infant should be placed in a side-lying position with the legs flexed. This position helps reduce edema and pressure on the surgical site, preventing strain and promoting comfort. Placing the infant supine with no head elevation (Choice A) doesn't offer adequate support and may increase pressure on the area. Side-lying with the legs extended (Choice C) doesn't help reduce edema and pressure effectively. Placing the infant supine with the head elevated 30 degrees (Choice D) isn't recommended as it may not provide adequate support and comfort needed for recovery.

2. A patient is being visited at home by a healthcare professional. The patient has been taking Naproxen for back pain. Which statement made by the patient most indicates that the healthcare professional needs to contact the physician?

A. I get an upset stomach if I don't take Naproxen with my meals.
B. My back pain right now is about a 3/10.
C. I get occasional headaches since taking Naproxen
D. I have ringing in my ears.

Correct answer: D

Rationale: The correct answer is 'I have ringing in my ears.' Ringing in the ears is a severe adverse effect of Naproxen, indicating potential toxicity. This symptom warrants immediate medical attention. Choices A, B, and C are less concerning and do not directly indicate a severe adverse effect or toxicity related to Naproxen. Upset stomach, mild back pain, and occasional headaches are common side effects that may not require immediate physician contact.

3. Which fact about diabetes is true?

A. Only children get type 1 diabetes.
B. Only adults get type 2 diabetes.
C. Children and adults can have type 1 diabetes.
D. Both A and B

Correct answer: C

Rationale: The correct answer is that children and adults can have type 1 diabetes. Although type 1 diabetes is sometimes known as 'childhood diabetes,' it can affect individuals of any age. Type 1 diabetes is not limited to children. While type 2 diabetes is often associated with adults, children can also develop it, especially due to factors like obesity. Choices A and B are incorrect because diabetes is not exclusive to either children or adults; both types of diabetes can affect individuals across different age groups.

4. When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?

A. The patient is offered a tissue from the box at the bedside.
B. A surgical face mask is applied before visiting the patient.
C. A snack is brought to the patient from the unit refrigerator.
D. Hand washing is performed before entering the patient's room.

Correct answer: B

Rationale: When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.

5. A systolic blood pressure of 145 mm Hg is classified as:

A. Normotensive
B. Prehypertension
C. Stage I hypertension
D. Stage II hypertension

Correct answer: C

Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.