NCLEX NCLEX-RN
NCLEX RN Predictor Exam
1. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
- A. The child is asked to undress from the waist up.
- B. The head is examined before the thorax, abdomen, and genitalia.
- C. The nurse should keep in mind that a child at this age will have a sense of modesty.
- D. Talking about the equipment being used is avoided to prevent increasing the child’s anxiety.
Correct answer: The nurse should keep in mind that a child at this age will have a sense of modesty.
Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.
2. The nurse is caring for clients in the pediatric unit. A 6-year-old patient is admitted with 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?
- A. A 4-year-old with sickle-cell disease
- B. A 12-year-old with chickenpox
- C. A 6-year-old undergoing chemotherapy
- D. A 7-year-old with a high temperature
Correct answer: A 4-year-old with sickle-cell disease
Rationale: The nurse should be concerned about the burn patient's vulnerability to infection due to compromised skin integrity. Sickle cell disease is not a communicable disease, so rooming the burn patient with a 4-year-old with sickle-cell disease would not pose an increased risk of infection transmission. Rooming the burn patient with a 12-year-old with chickenpox would increase the risk of infection for the burn patient. Rooming with a 6-year-old undergoing chemotherapy may expose the burn patient to potential infections. A 7-year-old with a high temperature could potentially have a contagious illness, which could be risky for the burn patient.
3. A healthcare professional is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
- A. S. pneumoniae
- B. H. influenzae
- C. N. meningitidis
- D. Cl. difficile
Correct answer: Cl. difficile
Rationale: The correct answer is Cl. difficile. Clostridium difficile (C. diff) is not typically associated with meningitis in humans. This bacterium is known to cause severe diarrhea, usually as a result of antibiotic treatment. S. pneumoniae, H. influenzae, and N. meningitidis are all known to be causative agents of meningitis in humans. S. pneumoniae is a common cause of bacterial meningitis, especially in adults. H. influenzae, particularly type b (Hib), used to be a leading cause of meningitis in children before the introduction of the Hib vaccine. N. meningitidis is another significant pathogen responsible for causing meningitis, especially in young adults and adolescents.
4. Which of the following is an example of restorative care?
- A. A nurse teaches a new mother how to breastfeed her infant
- B. A nurse helps a client with developing a bladder-retraining program
- C. A nurse places an allergy wristband on a client's wrist to notify other providers of potential reactions
- D. A nurse contacts the family of a client to tell them he will be out of surgery soon
Correct answer: A nurse helps a client with developing a bladder-retraining program
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function. Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (Choice A) is an example of educative care, placing an allergy wristband (Choice C) is a safety measure, and contacting a client's family to update them on surgery (Choice D) is related to communication and support, not restorative care.
5. The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.
- A. Client has an actual health problem
- B. Client has a wellness diagnosis
- C. Collaborative health problem needs to be written
- D. Possible nursing diagnosis exists
Correct answer: Client has a wellness diagnosis
Rationale: The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.
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