Nclex

A 14 month old boy is hospitalized with dehydration. He is unconsolable, screaming, and rejecting your physical contact. What best describes the infants response to you? • Separation anxiety-PROTEST PHRASE • Fear of injury and pain • Separation anxiety-DESPAIR • Loss of Control What nursing intervention would you NOT include in the plan of care with a two-year old experiecning loss of control? • Provide routines and rituals the 2-year old is familiar with. • Distract the...

1. You’re providing an in-service to a group of new nurses who will be caring for patients who have Tetralogy of Fallot. Which statement below is INCORRECT concerning how the blood normally flows through the heart? A. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium. B. The pulmonic valve receives blood from the right ventricle and allows blood to flow to the lungs via the pulmonary artery. C. The left atrium allows blood to flow down thro...

1. A newborn baby is born with transposition of the great arteries (TGA). You’re explaining the condition to the parents. Which statement by the father demonstrates he understood the education provided about this condition? A. “The pulmonary vein and artery are switched, which causes the pulmonary vein to deliver unoxygenated blood to the systemic circulation while the pulmonary artery delivers oxygenated blood back to the lungs.” B. “The aorta and pulmonary vein are switched, which ca...

1. A newborn is diagnosed with truncus arteriosus. You’re educating the parents about this heart defect. Which statement by the mother demonstrates she understood the education provided about this condition? A. “My baby has narrowing in the pulmonary artery, and the aorta is arising out of the right ventricle rather than the left ventricle.” B. “My baby’s heart shares one artery that connects the right and left ventricles.” C. “The left side of my baby’s heart is not fully dev...

1. True or False: Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right and left atria, which are the lower chambers of the heart. The answer is FALSE. Atrial septal defects are characterized by a hole in the interatrial septum that allows blood to mix in the right and left atria, which are the UPPER (not lower) chambers of the heart. 2. A patient is diagnosed with a large atrial septal defect. You’re providing information for the p...

1. A 15-month-old child weighs 26 lbs. and is 35 inches. What type of car seat below is considered the SAFEST for this child to use while riding in a motor vehicle? A. rear-facing B. forward-facing C. booster seat D. seat belt The answer is A. According the AAP (American Academy of Pediatrics) a child should use a rear-facing car seat starting at birth and up until the time the child outgrows the device based on the manufacture’s limits. This typically is until about 4 years of age. In 20...

1. Select all the true statements about the aorta: A. “The ascending aorta branches off to supply the coronary arteries of the heart.” B. “It’s the third largest artery in the body.” C. “The aorta comes off the right ventricle and supplies oxygenated blood to the body.” D. “The aortic arch branches off to supply the head, neck, and upper extremities.” The answers are A and D. These statements are true about the aorta. Option B is wrong because the aorta...

1. A 4 year old is admitted to your unit with a severe case of impetigo. It is important the nurse follows _______________ while providing care to this patient: A. Droplet precautions B. Standard precautions only C. Contact precautions D. Airborne precaution The answer is C. The nurse will follow contact precautions, which includes following standard precautions as well. Impetigo is a HIGHLY contagious skin infection. Therefore, the nurse should always where a gown and gloves when providing...

1. During an assessment of an infant, you note that when the infant’s head is turned to the right side, the leg and arm on the right side will extend, while the leg and arm on the left side will flex. You document this as what type of reflex? A. Rooting Reflex B. Sucking Reflex C. Moro Reflex D. Tonic Neck Reflex The answer is D. When the infant’s head is turned to a particular side, the leg and arm on that side will extend, while the leg and arm on the opposite side will flex. 2. Sele...