the nurse is developing a plan of care for an infant after surgical intervention for imperforate anus the nurse should include in the plan that which

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?

A. Prone position
B. Supine with no head elevation
C. Side-lying with the legs extended
D. Supine with the head elevated 45 degrees

Correct answer: A

Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site. Therefore, the correct choice is the prone position for this postoperative care scenario.

2. A patient suffering from hyperglycemia would be experiencing:

A. Low blood sugar
B. High blood sugar
C. Normal blood sugar
D. None of the above

Correct answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.

3. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?

A. Germs and viruses
B. Supernatural forces
C. Eating imbalanced (hot/cold) foods
D. Imbalance within his or her spiritual nature

Correct answer: B

Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.

4. During the general survey, what action is a component of the assessment?

A. Observing the patient's body stature and nutritional status
B. Interpreting the subjective information reported by the patient
C. Measuring the patient's temperature, pulse, respirations, and blood pressure
D. Observing specific body systems during the physical assessment

Correct answer: A

Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.

5. You are taking care of a patient who has active TB. The patient has been put on airborne precautions and is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading TB throughout the hospital?

A. Have everyone along the route to the radiology department wear a HEPA mask.
B. Have patients along the route to the radiology department wear a HEPA mask.
C. Have staff along the route to the radiology department wear a HEPA mask.
D. Place a HEPA mask on the patient.

Correct answer: D

Rationale: To prevent the spread of TB throughout the hospital, it is essential to place a HEPA mask on the patient before transporting them to the radiology department. Expecting everyone along the route to wear a HEPA mask is not practical due to the high cost and the need for special fittings. Having patients or staff wear HEPA masks along the route is also not feasible and may not effectively contain the spread of TB.