while planning care for a toddler the nurse teaches the parents about the expected developmental changes for this age which statement by the mother sh

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?

A. "I want to protect my child from any falls."?
B. "I will set limits on exploring the house."?
C. "I understand the need to use those new skills."?
D. "I intend to keep control over our child."?

Correct answer: C

Rationale: The correct answer is: "I understand the need to use those new skills."? This response indicates that the mother recognizes the importance of allowing the toddler to practice and develop new skills, supporting autonomy and exploration. Setting limits, protecting from falls, and intending to keep control go against the toddler's developmental needs. Toddlers at this stage require opportunities to explore, practice new skills, and gain independence to foster healthy development.

2. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

A. Use the old stock from a previous company
B. Verify the cuff pressures every hour to ensure accuracy
C. Notify the risk manager
D. Form a peer workgroup to evaluate new products

Correct answer: D

Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments. Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.

3. You are on the unit and overhear another nurse talking on the phone to a patient's friend who wants to see her patient who is comatose and on a ventilator. Since you cared for that patient yesterday, you know that the patient's significant other, who is also the designated healthcare surrogate (HCS) and has power of attorney (POA), has expressly stated that he wants this person on the list for restricted visitors. The nurse whispers that she'll call him to visit as soon as the significant other has gone home. What should your first response be?

A. Inform the significant other
B. Report the nurse to the nurse manager
C. Speak with the nurse directly in private
D. Call the visitor and tell him he can't visit

Correct answer: C

Rationale: Speaking with the nurse directly and privately is the most constructive manner in which to handle this situation and advocate for the significant other's wishes. Doing so will open communication with a peer and build the relationship, instead of alienating the other nurse by taking action that does not involve her and will cast her in a negative light with others. It is essential to express your concerns regarding honoring the significant other's requests and rights regarding the limitation of visitors. Option A is incorrect because the significant other is not the one trying to visit, and it is more appropriate to address the nurse directly first. Option B is not the best initial response as it may escalate the situation without giving the nurse a chance to correct the issue. Option D is incorrect as it does not address the issue at its source and may create further conflict without resolving the underlying problem.

4. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?

A. A 65-year old male with urine output of 60cc in the past four hours
B. A 2-month old female with a temperature of 100.6 rectally
C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
D. A 4-year old male with an oxygen saturation of 96% on room air

Correct answer: D

Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain

5. What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?

A. Decreasing amounts of body fat and muscle mass
B. Little change in body appearance from year to year
C. Progressive height increase of 4 inches each year
D. Yearly weight gain of about 5.5 pounds per year

Correct answer: D

Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.