Here are the Answers to NCLEX Preparation Course - Critical Thinking VI (61-70) -->
Situation: Baby Nicole is born with myelomeningocele.
61. Antibiotic therapy is started, but Baby Nicole's condition worsens. Which is a later sign of meningitis that the nurse should report?
a) hypothermia
b) opisthotonus
c) sunset the sign of the eyes
d) depressed fontanels
62. Six months after surgery, baby Nicole develops fever and convulsion. Which observation by the nurse would help confirm a diagnosis of meningitis?
a) rigidity of the lower extremities
b) increased pulse rate
c) high pitch cry
d) severe constipation
63. The nurse explains to the parents of Baby Nicole that even if the surgery was successful. Nicole need a continued health supervision of a:
a) cardiologist
b) dental hygienist
c) urologist
d) speech therapist
64. When Baby Nicole was 1 day old she has surgery for reduction of myelomeningocele. Which nursing intervention is critical during the postoperative period?
a) passive range-of-motion exercises of the lower extremities
b) suprapubic manual expression of urine
c) observation of the frequency and character of the stools
d) daily measurement of the head circumference
65. Which is the best position of Nicole before surgery?
a) trendelenburg's in the prone position
b) flat, on her side
c) semi fowler's on her side
d) prone position on her side
66. An internal fire drill is scheduled to be done in the hospital. To make beds available for the fire drill, who among these clients may be discharged?
a) the client with oral simplex virus whose culture is negative, temperature is 37.4C
b) the client with pneumonia, WBC is level 12,000/cu.mm.
c) the client with anemia whose hemoglobin level is 7.5g/dL
d) the client with renal failure with serum potassium level of 3 mEq/L
67. A nurse is caring for a client with a burn injury to the lower legs. Nitrofurazone (furacin) is prescribed to be applied to the site of injury. The nurse documents which of the following in the plan of care as the appropriate method to apply this medication?
a) apply dressings soaked with saline solution over the medication
b) apply 1-inch film directly to the burn sites
c) apply 1/16-inch film directly to the burn sites
d) apply 1/2-inch film directly to the burn sites
68. The nurse would expect to find which of the following:
a) abdominal rigidity
b) distended abdominal and umbilical veins
c) visible waves of peristalsis
d) rectal prolapse
69. Following surgery for Pyloric Stenosis, Hannah is started on glucose water. Infant formula is held until:
a) bowel sounds are detected
b) vital signs are stable
c) the infants is able to retain clear liquids
d) diarrhea is absent
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NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 61-70)
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