NATIONAL COUNCIL LICENSURE EXAMINATION
NCLEX Questions & Explanations (PT 2)
Questions With Complete Solutions
A 1-year-old child who goes to day care is recovering from an
episode of otitis media. Which intervention is most important for
the nurse to recommend to the parents in order to prevent
recurrence? Correct Answers Educational Outcome:
Otitis media (OM) is the inflammation or infection of the middle
ear resulting from dysfunction of the eustachian tube. OM
typically occurs in infants and children under age 2, sometimes
following a respiratory tract infection. The eustachian tubes in
infants and young children are short, straight, and fairly
horizontal, which results in ineffective drainage and protection
from respiratory secretions. Infants with exposure to tobacco
smoke are at risk for OM due to the resulting respiratory
inflammation. OM risk is also higher with activities such as
using a pacifier or drinking from a bottle when lying down as
these allow fluid to pool in the mouth and then reach the
eustachian tubes.
Key preventive measures include eliminating exposure to
smoke, obtaining routine immunizations to prevent infection,
and reducing or eliminating use of a pacifier after age 6 months.
A 14-year-old is seen in the sexually transmitted disease (STD)
outpatient department and diagnosed with gonorrhea. The client
tells the nurse of having sexual relations with only a 19-year-old
partner. What is the best response by the nurse? Correct
Answers Educational Outcome:
,To avoid re-infection with gonorrhea, it is essential that the
client's partner be tested and treated. During the visit, the nurse
should counsel the client about the importance of partner
evaluation and treatment and the likely recurrence of the
infection if the partner refuses to be treated. The client should
avoid sexual relations until treatment is completed and the client
and partner no longer have symptoms.
A 19-year-old having sexual relations with a 14-year-old is
considered statutory rape and is reportable to child protective
services or local law enforcement. However, it is most important
in this situation to ensure that the client and partner receive
appropriate testing and effective treatment. If the client is told
that the two are going to be reported to the local authorities,
there is a high probability that the client will leave the clinic
without being treated and the partner will never come in.
A 3-month-old infant is treated in the emergency department for
a spiral femur fracture. The parent reports that the infant
sustained the injury after rolling off the bed. What is the priority
nursing action? Correct Answers Educational Outcome:
The parent's account of this injury is inconsistent with the
developmental milestones of a 3-month-old, because the
muscles required for rolling over do not develop until age 6
months. Additionally, spiral femur fractures indicate that
pressure was applied to the leg in opposite directions (torsion),
which is an unlikely accidental injury in a nonambulatory child.
Fractures in young children, especially nonambulatory, are
always concerning and suspicious of child abuse. The nurse's
priority is to report suspected child maltreatment to the
,appropriate authorities following facility protocol as required by
law in the United States and Canada .
However, the nurse should also be aware of cultural health
practices (eg, cupping, coining) and physiologic conditions (eg,
hemophilia, congenital dermal melanocytosis) mimicking
maltreatment.
After reporting suspected maltreatment, the nurse should
facilitate a complete physical evaluation (eg, skeletal survey,
growth/development comparisons, radiographic studies,
neurologic examination)
A 6-month-old client has been diagnosed with cystic fibrosis.
Which of the following would be appropriate for the registered
nurse to teach to the parents? Correct Answers Educational
Outcome:
Over time, airways develop chronic colonization and frequent
respiratory infections result. Bronchial hygiene therapy, such as
manual chest physiotherapy, is used. For physiotherapy, various
positions are used, and this should be performed before meals to
avoid a full stomach and resultant regurgitation or vomiting
A 62-year-old client is scheduled for open abdominal aneurysm
repair. What key assessment should be made by the nurse
preoperatively? Correct Answers Educational Outcome:
Comparison of blood pressures in each arm may be helpful in an
assessment of an upper aortic dissection or congenital aortic
coarctation, but not in assessing an abdominal aortic aneurysm.
, A charge nurse is monitoring a newly licensed registered nurse.
What action by the new nurse would warrant intervention by the
charge nurse? Correct Answers Occasional premature
ventricular contractions (PVCs) in the normal heart are not
significant. PVCs in the client with coronary artery disease or
myocardial infarction indicate ventricular irritability and may
lead to life-threatening dysrhythmia such as ventricular
tachycardia
A client arrives at the clinic for a follow-up after an emergency
department visit the night before. The client sustained an ulnar
fracture, and a fiberglass cast was applied. Which of the
following teachings related to cast care should the nurse
reinforce? Select all that apply. Correct Answers Educational
Outcome:
Casts (eg, fiberglass, plaster) are applied to immobilize fractured
extremities during healing. Instructions for cast care include:
Report foul odors or hot areas (hot spots) in the cast, which may
indicate infection.
Avoid getting the cast wet, which may damage the cast and
cause skin irritation/infection.
Elevate the affected extremity above heart level for the first 48
hours to reduce edema.
Regularly perform isometric and range of motion exercises to
prevent muscle atrophy.
NCLEX Questions & Explanations (PT 2)
Questions With Complete Solutions
A 1-year-old child who goes to day care is recovering from an
episode of otitis media. Which intervention is most important for
the nurse to recommend to the parents in order to prevent
recurrence? Correct Answers Educational Outcome:
Otitis media (OM) is the inflammation or infection of the middle
ear resulting from dysfunction of the eustachian tube. OM
typically occurs in infants and children under age 2, sometimes
following a respiratory tract infection. The eustachian tubes in
infants and young children are short, straight, and fairly
horizontal, which results in ineffective drainage and protection
from respiratory secretions. Infants with exposure to tobacco
smoke are at risk for OM due to the resulting respiratory
inflammation. OM risk is also higher with activities such as
using a pacifier or drinking from a bottle when lying down as
these allow fluid to pool in the mouth and then reach the
eustachian tubes.
Key preventive measures include eliminating exposure to
smoke, obtaining routine immunizations to prevent infection,
and reducing or eliminating use of a pacifier after age 6 months.
A 14-year-old is seen in the sexually transmitted disease (STD)
outpatient department and diagnosed with gonorrhea. The client
tells the nurse of having sexual relations with only a 19-year-old
partner. What is the best response by the nurse? Correct
Answers Educational Outcome:
,To avoid re-infection with gonorrhea, it is essential that the
client's partner be tested and treated. During the visit, the nurse
should counsel the client about the importance of partner
evaluation and treatment and the likely recurrence of the
infection if the partner refuses to be treated. The client should
avoid sexual relations until treatment is completed and the client
and partner no longer have symptoms.
A 19-year-old having sexual relations with a 14-year-old is
considered statutory rape and is reportable to child protective
services or local law enforcement. However, it is most important
in this situation to ensure that the client and partner receive
appropriate testing and effective treatment. If the client is told
that the two are going to be reported to the local authorities,
there is a high probability that the client will leave the clinic
without being treated and the partner will never come in.
A 3-month-old infant is treated in the emergency department for
a spiral femur fracture. The parent reports that the infant
sustained the injury after rolling off the bed. What is the priority
nursing action? Correct Answers Educational Outcome:
The parent's account of this injury is inconsistent with the
developmental milestones of a 3-month-old, because the
muscles required for rolling over do not develop until age 6
months. Additionally, spiral femur fractures indicate that
pressure was applied to the leg in opposite directions (torsion),
which is an unlikely accidental injury in a nonambulatory child.
Fractures in young children, especially nonambulatory, are
always concerning and suspicious of child abuse. The nurse's
priority is to report suspected child maltreatment to the
,appropriate authorities following facility protocol as required by
law in the United States and Canada .
However, the nurse should also be aware of cultural health
practices (eg, cupping, coining) and physiologic conditions (eg,
hemophilia, congenital dermal melanocytosis) mimicking
maltreatment.
After reporting suspected maltreatment, the nurse should
facilitate a complete physical evaluation (eg, skeletal survey,
growth/development comparisons, radiographic studies,
neurologic examination)
A 6-month-old client has been diagnosed with cystic fibrosis.
Which of the following would be appropriate for the registered
nurse to teach to the parents? Correct Answers Educational
Outcome:
Over time, airways develop chronic colonization and frequent
respiratory infections result. Bronchial hygiene therapy, such as
manual chest physiotherapy, is used. For physiotherapy, various
positions are used, and this should be performed before meals to
avoid a full stomach and resultant regurgitation or vomiting
A 62-year-old client is scheduled for open abdominal aneurysm
repair. What key assessment should be made by the nurse
preoperatively? Correct Answers Educational Outcome:
Comparison of blood pressures in each arm may be helpful in an
assessment of an upper aortic dissection or congenital aortic
coarctation, but not in assessing an abdominal aortic aneurysm.
, A charge nurse is monitoring a newly licensed registered nurse.
What action by the new nurse would warrant intervention by the
charge nurse? Correct Answers Occasional premature
ventricular contractions (PVCs) in the normal heart are not
significant. PVCs in the client with coronary artery disease or
myocardial infarction indicate ventricular irritability and may
lead to life-threatening dysrhythmia such as ventricular
tachycardia
A client arrives at the clinic for a follow-up after an emergency
department visit the night before. The client sustained an ulnar
fracture, and a fiberglass cast was applied. Which of the
following teachings related to cast care should the nurse
reinforce? Select all that apply. Correct Answers Educational
Outcome:
Casts (eg, fiberglass, plaster) are applied to immobilize fractured
extremities during healing. Instructions for cast care include:
Report foul odors or hot areas (hot spots) in the cast, which may
indicate infection.
Avoid getting the cast wet, which may damage the cast and
cause skin irritation/infection.
Elevate the affected extremity above heart level for the first 48
hours to reduce edema.
Regularly perform isometric and range of motion exercises to
prevent muscle atrophy.
