NCLEX-RN
NCLEX RN Exam Review Answers
1. Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?
- A. Pickle
- B. Wheat toast
- C. Baked chicken
- D. Steamed vegetables
Correct answer: A
Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.
2. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
- A. Prone position
- B. On the stomach
- C. Left lateral position
- D. Right lateral position
Correct answer: C
Rationale: After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.
3. A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?
- A. It is an acute bowel obstruction.
- B. It is a condition that causes an acute inflammatory process in the bowel.
- C. It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel.
- D. It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel.
Correct answer: D
Rationale: Intussusception is a condition in which a proximal segment of the bowel telescopes or prolapses into a distal segment of the bowel. This leads to bowel obstruction and potential ischemia. It is not an acute bowel obstruction, as the obstruction is caused by the telescoping of bowel segments rather than a blockage in the bowel lumen. Intussusception is not primarily an inflammatory process; instead, it is a mechanical issue involving bowel invagination. Choice A is incorrect as it does not accurately describe the pathophysiology of intussusception. Choice C is incorrect because it presents the opposite scenario of what happens in intussusception.
4. A healthcare professional is reviewing a patient's chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?
- A. Yersinia pestis
- B. Helicobacter pylori
- C. Vibrio cholerae
- D. Haemophilus aegyptius
Correct answer: D
Rationale: The correct answer is Haemophilus aegyptius. Haemophilus influenzae biogroup aegyptius (Hae) is a causative agent of acute and often purulent conjunctivitis, more commonly known as pink eye. Yersinia pestis, Helicobacter pylori, and Vibrio cholerae are not associated with conjunctivitis. Yersinia pestis causes the plague, Helicobacter pylori is associated with gastric ulcers, and Vibrio cholerae causes cholera.
5. A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct answer: D
Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems. Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.
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