NCLEX-PN Practice Exam 20
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
The suggested diet for the client with AIDS is one that is high calorie, high protein, and low fat. Clients with AIDS have a reduced tolerance to fat because of the disease as well as side effects from some antiviral medications; therefore, answers A and C are incorrect. Answer B is incorrect because the client needs a high-protein diet.
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
The nurse can help ready the child with cerebral palsy for speech therapy by providing activities that help the child develop tongue control. Most children with cerebral palsy have visual and auditory difficulties that require glasses or hearing devices rather than rehabilitative training; therefore, answers A and C are incorrect. Answer D is incorrect because video games are not appropriate for the age or developmental level of the child with cerebral palsy.
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
Most infants begin nocturnal sleep lasting 9–11 hours by 3–4 months of age. Answers A and B are incorrect because the infant is still waking for nighttime feedings. Answer D is incorrect because it does not answer the question.
Which of the following pediatric clients is at greatest risk for latex allergy?
The child with myelomeningocele is at greatest risk for the development of latex allergy because of repeated exposure to latex products during surgery and from numerous urinary catheterizations. Answers B, C, and D are much less likely to be exposed to latex; therefore, they are incorrect.
The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to:
The nurse or parent should use a cupped hand when performing chest percussion. Answer A is incorrect because the hand should be cupped. Answer B is incorrect because the child’s position should be changed every 5–10 minutes and the whole session should be limited to 20 minutes. Answer D is incorrect because chest percussion should be done before meals.
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
No more than 1mL should be given in the vastus lateralis of the infant. Answers B, C, and D are incorrect because the dorsogluteal and ventrogluteal muscles are not used for injections in the infant.
A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in:
Depot injections of Haldol are administered every 4 weeks. Answers A and B are incorrect because the medication is still in the client’s system. Answer D is incorrect because the medication has been eliminated from the client’s system, which allows the symptoms of schizophrenia to return.
A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
Tucking a disposable diaper at the perineal opening will help prevent soiling of the cast by urine and stool. Answer A is incorrect because the head of the bed should be elevated. Answer B is incorrect because the child can place the crayons beneath the cast, causing pressure areas to develop. Answer C is incorrect because the child does not need high-calorie foods that would cause weight gain while she is immobilized by the cast.
The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?
Coolness and discoloration of the reimplanted digits indicates compromised circulation, which should be reported immediately to the physician. The temperature should be monitored, but the client would receive antibiotics to prevent infection; therefore, answer A is incorrect. Answers C and D are expected following amputation and reimplantation; therefore, they are incorrect.