NCLEX Daily Ten Question Practical Exercise 5

Welcome to our NCLEX Daily Ten Practice! This practice is designed to help you solidify your knowledge, improve your skills, and prepare thoroughly for the NCLEX exam. With ten questions to tackle each day, you’ll have the opportunity to review a broad range of subjects covered in the NCLEX exam.

 

1. The pediatric nurse is providing education to caregivers regarding nutrition and eating habits in children.  Which of the following caregiver statements shows understanding?

A. “I give my child ice cream when he gets a good grade in school.”

B. “My child must eat his entire plate of food before leaving the table.”
C. “A handful of grapes are an appropriate snack for my 11-month-old child.”

D. “It is okay if all my toddler eats is chicken nuggets and apples 2 days in a row.”

Correct Answer: D

Answer Explanation:

Adequate nutrition and healthy eating habits for pediatric clients ensure proper growth and development and promote a lifetime of good dietary decisions. Teaching centers around choosing balanced and appropriate meals and supporting a healthy relationship with food.

Teaching was effective if the caregiver demonstrates understanding of the following teaching: Picky eating is common in young children as they learn to control their environment and develop independent thinking skills. Understanding a child’s preferences and routines allows parents to plan a balanced nutritional diet around a full week. It is important to offer a variety of nutritious foods throughout the week for optimal nutrition during this stage instead of trying to achieve the same variety within a single day.

2. The nurse has received a change-of-shift report on the following pediatric clients. It would be a priority for the nurse to follow up with the?

A. 7-year-old client recovering from a tonsillectomy who reports pain with swallowing
B. 4-year-old client diagnosed with Kawasaki disease with a fever of 102.5°F (39.2°C)
C. 6-year-old client with a tracheostomy who is coughing and has copious thick secretions
D. 17-year-old client diagnosed with persistent asthma who had scheduled budesonide due 1 hour ago

Correct Answer: C

Answer Explanation:

A tracheostomy is an artificial airway created by an opening in the trachea. Thick, copious tracheostomy secretions can obstruct airflow within the airway and cause coughing, an early sign of respiratory distress. The nurse should provide interventions to ensure a patent airway and prevent further respiratory distress (e.g., humidification, suctioning).

3. The nurse is preparing to administer oxygen via a non-rebreather mask for a client with hypoxemia. Which of the following actions should the nurse take?

A. Set the oxygen rate to 15 liters per minute.
B. Ensure the bag fully inflates during exhalation.
C. Apply petroleum jelly to the nares to prevent drying.
D. Ensure one-way valves on the facemask remain closed during exhalation.

Correct Answer: A

Answer Explanation:

Nonrebreather masks deliver oxygen therapy for clients experiencing severe hypoxemia and requiring high oxygen concentrations (e.g., carbon monoxide poisoning, smoke inhalation). Nonrebreather masks require a 10-15 L/min flow rate to inflate the oxygen reservoir bag. If the flow rate is insufficient, the client cannot inhale enough oxygen and is at risk for suffocation.

4. The nurse is assessing a client who had a colostomy 24 hours ago. Which of the following stoma findings would require immediate follow-up?

A. Shiny, red, and edematous
B. 1-cm dark reddish-purple area
C. Slight serosanguineous drainage
D. Protrusion of 2 centimeters from abdominal wall

Correct Answer: B

Answer Explanation:

An ostomy is a surgically created opening from the gastrointestinal tract onto the abdomen. A colostomy opens into the colon and occurs at various sites depending on the surgical reason (e.g., colorectal cancer, bowel perforation, diverticulosis). The stoma is composed of intestinal tissue and is visible on the abdomen. Healthy stomas are shiny, red, and slightly edematous at first. A stoma that appears gray, dark red, bluish, or purplish indicates ischemia and should be reported to the health care provider immediately.

5. The nurse is caring for a confused older adult client who is a fall risk and keeps attempting to get out of bed to go to the bathroom. Which of the following actions should the nurse take?

A. Decrease stimulation by turning off lights.
B. Give the client some magazines for reading.
C. Insert an indwelling urinary catheter to limit bathroom trips.
D. Administer diphenhydramine at night to help the client sleep.

Correct Answer: B

Answer Explanation:

Restraints can be physical (e.g., mittens) or chemical (e.g., sedatives) and are used to keep clients safe; however, the nurse should always try less restrictive measures first. The client is at risk for falls and should be given diversional activities to distract the client from attempting to get out of bed (e.g., magazines, folding towels, games, art). In addition, the nurse should schedule routine ambulation to assist the client to the bathroom and reduce the client’s attempts to get up alone.

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