Exam (elaborations)
NCLEX 10,000 TEST 4 LATEST VERSIONS REAL EXAM 160 QUESTIONS AND CORRECT ANSWERS |AGRADE
- Course
- Institution
NCLEX 10,000 TEST 4 LATEST VERSIONS REAL EXAM 160 QUESTIONS AND CORRECT ANSWERS |AGRADE
[Show more]
Content preview
NCLEX 10,000NCLEX 10,000 TEST 4 LATEST
VERSIONS REAL EXAM 160
QUESTIONS AND CORRECT ANSWERS
|AGRADE
Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA)
regulations?
a) Two nurses in the cafeteria are discussing a client's condition.
b) The health care team is discussing a client's care during a formal care conference.
c) A nurse checks the computer for the laboratory results of a neighbor who has been admitted to
another floor.
d) A nurse talks with her spouse about a client's condition. - ✔✔ANSWER✔✔-b - To provide
interdisciplinary continuity of care, nurses must share relevant information during client care
conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates
,HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a
client's condition with one's spouse.
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that
the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary
health care provider is notified because the nurse suspects which of the following?
a. phimosis
b. hydrocele
c. epispadias
d. hydrospadias - ✔✔ANSWER✔✔-d - The condition in which the urinary meatus is located on the
ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is
delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is
an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis
may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum
that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the
urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly
associated with bladder extrophy.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs hand
washing and dons clean gloves. Which of the following should the nurse do next?
a. place the non-dominant hand above the symphysis pubis and the dominant hand at the umbilicus
b. ask the client to assume a side-lying position with the knees flexed
c. perform massage vigorously at the level of the umbilicus if the fundus feels boggy
d. place the client on a bedpan in case the uterine palpation stimulates the client to void -
✔✔ANSWER✔✔-D - The nurse should place the non-dominant hand above the symphysis pubis
and the dominant hand at the umbilicus to palpate the fundus. This prevents the uterine inversion and
trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not
side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal
pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels
boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again.
The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to
the client, the uterus to be deviated to one side, and postpartum hemorrhage.
A 10-month-old child has cold symptoms. The mother asks how she can clear infant's nose. Which of the
following would be the nurse's best recommendation?
,a. use a cool air vaporizer with plain water
b. use saline nose drops and then a bulb syringe
c. blow into the child's mouth to clear the nose
d. administer a nonprescription vasoconstrictive nose spray. - ✔✔ANSWER✔✔-b - although a cool
air vaporizer may be recommended to humidify the environment, using saline nose drops and then a
bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline
helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in
removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more
organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants
because if the spray in used for longer than 3 days a rebound effect with increased inflammation occurs.
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help
determine the cause of the child's condition, the nurse should ask the parents:
a) "Does water ever get into the baby's ears during shampooing?"
b) "Do you give the baby a bottle to take to bed?"
c) "Have you noticed a lot of wax in the baby's ears?"
d) "Can the baby combine two words when speaking?" - ✔✔ANSWER✔✔-b - In a young child, the
eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the
nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate
because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk
of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect
because wax doesn't promote the development of otitis media. During shampooing, water may become
trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external
ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words
is incorrect because a 10-month-old child isn't expected to do so.
A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse
should ensure that which action is a part of the child's care?
a) Taking vital signs every 4 hours and obtaining daily weight
b) Obtaining a blood sample for electrolyte analysis every morning
c) Checking every urine specimen for protein and specific gravity
, d) Ensuring that the child has accurate intake and output and eats a high-protein diet -
✔✔ANSWER✔✔-a) CORRECT ANSWER Taking vital signs every 4 hours and obtaining daily weight
Reason: Because major complications — such as hypertensive encephalopathy, acute renal failure, and
cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important
measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and
output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be
ordered depending on the severity of the edema and the extent of impaired renal function. Typically,
protein intake remains normal for the child's age and is only increased if the child is losing large amounts
of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of
serum electrolyte levels may be done, but their frequency is determined by the child's status. These
actions are less important nursing measures in this situation.
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should
immediately:
a) Put the client to bed.
b) Obtain the child's blood pressure.
c) Notify the physician.
d) Administer acetaminophen (Tylenol). - ✔✔ANSWER✔✔-b) CORRECT ANSWER Obtain the child's
blood pressure.
Reason: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred
vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to
the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume
excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before
confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client
to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood
pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not
recommended.
A 16-year-old academically gifted boy is about to graduate from high school early, because he has
completed all courses needed to earn a diploma. Within the last 3 months, he has experienced panic
attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned
that these attacks may hinder his ability to pursue a college degree. What would be the best response
by the school nurse who has been helping him deal with his panic attacks?
a) "It is natural to be worried about going into a new environment. I am sure with your abilities you will
do well once you get settled."
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller doctorfirstbest. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $25.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
73314 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now