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  1. Home
  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 216

Hematotympanum and otorrhea are associated with which of the following head injuries?

Correct Answer: A
Explanation
(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.
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Question 217

A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

Correct Answer: C
(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
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Question 218

A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

Correct Answer: A
Explanation/Reference:
Explanation:
(A) Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. (B) Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. (C) Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time.
(D) These side effects do not necessarily resolve in time; however, the client may adapt.
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Question 219

A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?

Correct Answer: C
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
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Question 220

Following a fracture of the left femur, a client develops symptoms of osteomyelitis. During the acute phase of osteomyelitis, nursing care is directed toward:

Correct Answer: A
Explanation/Reference:
Explanation:
(A) Any movement of his affected limb will cause discomfort to the child. (B) No weight bearing will be allowed until healing is well underway to avoid pathological fractures. (C) The child will be anorexic and may experience vomiting. Diet should be simple and high caloric until appetite returns and symptoms subside. (D) Physical therapy is instituted only after infection subsides.
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