1. A 14-month-old child recently arrived in the United States from a foreign country with his parents and needs childhood immunizations. His mother reports that he is allergic to eggs. Upon further questioning, you determine that the allergy to eggs is anaphylaxis. Which of the following vaccines should he not receive?
a. Hepatitis B
b. Inactivated polio
c. Diphtheria, acellular pertussis, tetanus (DTaP)
d. Mumps, measles, rubella (MMR)

Answer B

Rationale: The measles portion of the MMR vaccine is grown in chick embryo cells. The current MMR vaccine does not contain a significant amount of egg proteins, and even children with dramatic egg allergies are extremely unlikely to have an anaphylactic reaction. However, patients that do respond to egg contact with anaphylaxis should be in a medically controlled setting where full resuscitation efforts can be administered if anaphylaxis results. The vaccines in options 1-3 do not contain egg protein.

2. The Gell and Coombs classification system categorizes allergic reactions and is useful in describing and classifying patient reactions to drugs. Type I reactions are immediate hypersensitivity reactions and are mediated by:
a. Immunoglobulin E (IgE)
b. Immunoglobulin G (IgG)
c. Immunoglobulin A (IgA)
d. Immunoglobulin M (IgM).

Answer A

Rationale: IgE, the least common serum immunoglobulin (Ig) binds very tightly to receptors on basophils and mast cells and is involved in allergic reactions. Binding of the allergen to the IgE on the cells results in the release of various pharmacological mediators that result in allergic symptoms. IgG is the major Ig (75 percent of serum Ig is IgG). Most versatile Ig because it is capable of carrying out all of the functions of Ig molecules. IgG is the only class of Ig that crosses the placenta. It is an opsonin, a substance that enhances phagocytosis. IgA, the second most common serum Ig is found in secretions (tears, saliva, colostrum, and mucus). It is important in local (mucosal) immunity. IgM, the third most common serum Ig, is the first Ig to be made by the fetus and the first Ig to be made by a virgin B cell when it is stimulated by antigen. IgM antibodies are very efficient in leading to the lysis of microorganisms.

3. Drugs can cause adverse events in a patient. Bone marrow toxicity is one of the most frequent types of drug-induced toxicity. The most serious form of bone marrow toxicity is:
a. Aplastic anemia
b. Thrombocytosis
c. Leukocytosis
d. Granulocytosis

Answer A

Rationale: Aplastic anemia is the result of a hypersensitivity reaction and is often irreversible. It leads to pancytopenia, a severe decrease in all cell types: red blood cells, white blood cells, and platelets. A reduced number of red blood cells causes hemoglobin to drop. A reduced number of white blood cells makes the patient susceptible to infection. And, a reduced number of platelets causes the blood not to clot as easily. Treatment for mild cases is supportive. Transfusions may be necessary. Severe cases require a bone marrow transplant. Option 2 is an elevated platelet count. Option 3 is an elevated white count. Option 4 is an elevated granulocyte count. A granulocyte is a type of white blood cell.

4. Serious adverse effects of oral contraceptives include:
a. Increase in skin oil followed by acne.
b. Headache and dizziness.
c. Early or mid-cycle bleeding.
d. Thromboembolic complications.

Answer B

Rationale: Oral contraceptives have been associated with an increased risk of stroke, myocardial infarction, and deep vein thrombosis. These risks are increased in women who smoke. Increased skin oil and acne are effects of progestin excess. Headache and dizziness are effects of estrogen excess. Early or mid-cycle bleeding are effects of estrogen deficiency.

5. The most serious adverse effect of Alprostadil (Prostin VR pediatric injection) administration in neonates is:
a. Apnea
b. Bleeding tendencies
c. Hypotension
d. Pyrexia

Answer: A

Rationale: All items are adverse reactions of the drug. However, apnea appearing during the first hour of drug infusion occurs in 10-12 percent of neonates with congenital heart defects. Clinicians deciding to utilize alprostadil must be prepared to intubate and mechanically ventilate the infant. Careful monitoring for apnea or respiratory depression is mandatory. In some institutions, elective intubation occurs prior to initiation of the medication.

1. A patient asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always require cross-matching?
a. Packed red blood cells
b. Platelets
c. Plasma
d. Granulocytes

Answer A

Rationale: Red blood cells contain antigens and antibodies that must be matched between donor and recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no cross-match.

2. A month after receiving a blood transfusion an immunocompromised patient develops fever, liver abnormalities, a rash, and diarrhea. The nurse would suspect this patient has:
a. Nothing related to the blood transfusion.
b. Graft-versus-host disease (GVHD).
c. Myelosuppression.
d. An allergic response to a recent medication.

Answer B

Rationale: GVHD occurs when white blood cells in donor blood attack the tissues of an immunocompromised recipient. This process can occur within a month of the transfusion. Options 1 and 4 may be a thought, but the nurse must remember that immunocompromised transfusion recipients are at risk for GVHD.

3. A client comes into the local blood donation center. He says he is here to donate platelets only today. The nurse knows this process is called:
a. Directed donation.
b. Autologous donation.
c. Allogenic donation.
d. Apheresis.

Answer B

Rationale: The process of apheresis involves removal of whole blood from a donor. Within an instrument that is essentially designed as a centrifuge, the components of whole blood are separated. One of the separated portions is then withdrawn, and the remaining components are retransfused into the donor. Directed donation is collected from a blood donor other than the recipient, but the donor is known to the recipient and is usually a family member or friend. Autologous donation is the collection and reinfusion of the patient’s own blood. Allogenic donation is collected from a blood donor other than the recipient.

4. The nurse knows that the age group that uses the most units of blood and blood products is:
a. Premature infants.
b. Children ages 1-20 years.
c. Adults ages 21-64 years.
d. The elderly above age 65 years.

Answer B

Rationale: People older than 65 years use 43 percent of donated blood. This number is expected to increase as the population ages.

5. A child is admitted with a serious infection. After two days of antibiotics, he is severely neutropenic. The physician orders granulocyte transfusions for the next four days. The mother asks the nurse why? The nurse responds:
a. “This is the only treatment left to offer the child.”
b. “This therapy is fast and reliable in treating infections in children.”
c. “The physician will have to explain his rationale to you.”
d. “Granulocyte transfusions replenish the low white blood cells until the body can produce its own.”

Answer B

Rationale: Granulocyte (neutrophil) replacement therapy is given until the patient’s blood values are normal and he is able to fight the infection himself. Options 1 and 3 are not therapeutic responses. The treatment in option 2 takes days and is not always able to prevent morbidity and mortality.

NCLEX Questions for Pharmacologies Therapies 1/5

NCLEX Questions for Pharmacologies Therapies 2/5

NCLEX Questions for Pharmacologies Therapies 3/5

NCLEX Questions for Pharmacologies Therapies 5/5

1. A teenage patient is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?
a. Lungs
b. Liver
c. Kidneys
d. Adrenal glands

Answer B

Rationale: Acetaminophen is extensively metabolized by pathways in the liver. Toxic doses of acetaminophen deplete hepatic glutathione, resulting in accumulation of the intermediate agent, quinine, which leads to hepatic necrosis. Prolonged use of acetaminophen may result in an increased risk of renal dysfunction, but a single overdose does not precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands.

2. A contraindication for topical corticosteroid usage in a patient with atopic dermatitis (eczema) is:
a. Parasite infection
b. Viral infection
c. Bacterial infection
d. Spirochete infection

Answer B

Rationale: Topical agents produce a localized, rather than systemic effect. When treating atopic dermatitis with a steroidal preparation, the site is vulnerable to invasion by organisms. Viruses, such as herpes simplex or varicella-zoster, present a risk of disseminated infection. Educate the patient using topical corticosteroids to avoid crowds or people known to have infections and to report even minor signs of an infection. Topical corticosteroid usage results in little danger of concurrent infection with these agents.

3. In infants and children, the side effects of first generation over-the-counter (OTC) antihistamines, such as diphenhydramine (Benedryl) and hydroxyzine (Atarax) include:
a. Reye’s syndrome.
b. Cholinergic effects.
c. Paradoxical CNS stimulation.
d. Nausea and diarrhea.

Answer C

Rationale: Typically, first generation OTC antihistamines have a sedating effect because of passage into the CNS. However, in some individuals, especially infants and children, paradoxical CNS stimulation occurs and is manifested by excitement, euphoria, restlessness, and confusion. For this reason, use of first generation OTC antihistamines has declined, and second generation product usage has increased. Reye’s syndrome is a systemic response to a virus. First generation OTC antihistamines do not exhibit a cholinergic effect. Nausea and diarrhea are uncommon when first generation OTC antihistamines are taken.

4. Reye’s syndrome, a potentially fatal illness associated with liver failure and encephalopathy is associated with the administration of which over-the-counter (OTC) medication?
a. Acetaminophen (Tylenol)
b. Ibuprofen (Motrin)
c. Aspirin
d. Brompheniramine/psudoephedrine (Dimetapp)

Answer C

Rationale: Virus-infected children who are given aspirin to manage pain, fever, and inflammation are at an increased risk of developing Reye’s syndrome. Use of acetaminophen has not been associated with Reye’s syndrome and can be safely given to patients with fever due to viral illnesses. Ibuprofen adverse effects include GI irritation and bleeding, and in toxic doses, both renal and hepatic failure are reported. However, ibuprofen has not been associated with the onset of Reye’s disease. Brompheniramine/psudoephedrine contains a first generation OTC antihistamine and a decongestant. Neither agent has been associated with the development of Reye’s syndrome.

5. Patients who are allergic to intravenous contrast media are usually also allergic to which of the following products?
a. Eggs
b. Shellfish
c. Soy
d. Acidic fruits

Answer B

Rationale: Some types of contrast media contain iodine as an ingredient. Shellfish also contain significant amounts of iodine. Therefore, a patient who is allergic to iodine will exhibit an allergic response to both iodine containing contrast media and shellfish. These products do not contain iodine.

NCLEX Questions for Pharmacologies Therapies 1/5

NCLEX Questions for Pharmacologies Therapies 2/5

NCLEX Questions for Pharmacologies Therapies 4/5

NCLEX Questions for Pharmacologies Therapies 5/5

1. Your patient calls the clinic today because he is taking atorvastatin (Lipitor) to treat his high cholesterol and is having pain in both of his legs. You instruct him to:
a. Stop taking the drug and make an appointment to be seen next week
b. Continue taking the drug and make an appointment to be seen next week.
c. Stop taking the drug and come to the clinic to be seen today.
d. Walk for at least 30 minutes and call if symptoms continue.

Answer C

Rationale: Muscle aches, soreness, and weakness may be early signs of myopathy such as rhabdomyolysis associated with the HMG-CoA reducatase class of antilipemic agents. This patient will need an immediate evaluation to rule out myopathy. Additional doses may exacerbate the problem. Exercise will not reverse myopathy and delays diagnosis.

2. Which of the following adverse effects is associated with levothyroxine (Synthroid) therapy?
a. Tachycardia
b. Bradycardia
c. Hypotension
d. Constipation

Answer A

Rationale: Levothyroxine, especially in higher doses, can induce hyperthyroid-like symptoms including tachycardia. An agent that increases the basal metabolic rate would not be expected to induce a slow heart rate. Hypotension would be a side effect of bradycardia. Constipation is a symptom of hypothyroid disease.

3. Which of the following adverse effects is specific to the biguanide diabetic drug metformin (Glucophage) therapy?
a. Hypoglycaemia
b. GI distress
c. Lactic acidosis
d. Somulence

Answer C

Rationale: Lactic acidosis is the most dangerous adverse effect of metformin administration with death resulting in approximately 50 percent of individuals who develop lactic acidosis while on this drug. Metformin does not induce insulin production; thus, administration does not result in hypoglycemic events. Some nausea, vomiting, and diarrhea may develop but is usually not severe. NVD is not specific for metformin. Metformin does not induce sleepiness.

4. The most serious adverse effect of tricyclic antidepressant (TCA) overdose is:
a. Seizures
b. Hyperpyrexia
c. Metabolic acidosis
d. Cardiac arrhythmias

Answer B

Rationale: Excessive ingestion of TCAs result in life-threatening wide QRS complex tachycardia. TCA overdose can induce seizures, but they are typically not life-threatening. TCAs do not cause an elevation in body temperature. TCAs do not cause metabolic acidosis.

5. Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a patient?
a. 0.9 percent sodium chloride
b. 2.5 percent dextrose in water solution
c. Sterile water
d. Peparin sodium

Answer A

Rationale: 0.9 percent sodium chloride is normal saline. This solution has the same osmolarity as blood. Its use prevents red cell lysis. The solutions given in options 2 and 3 are hypotonic solutions and can cause red cell lysis. The solution in option 4 may anticoagulate the patient and result in bleeding.

NCLEX Questions for Pharmacologies Therapies 1/5

NCLEX Questions for Pharmacologies Therapies 3/5

NCLEX Questions for Pharmacologies Therapies 4/5

NCLEX Questions for Pharmacologies Therapies 5/5

1. A neighbor tells a nurse he has to have surgery and is reluctant to have any blood product transfusions because of a fear of contracting an infection. He asks the nurse what are his options. The nurse teaches the person that the safest blood product is:
a. An allogenic product.
b. A directed donation product.
c. An autologous product.
d. A cross-matched product.

Answer C

Rationale: This process is the collection and reinfusion of the patient’s own blood. It is recommended by the American Medical Association’s Council on Scientific Affairs as the safest product since it eliminates recipient incompatibility and infection. The product in option 1 is collected from a blood donor other than the recipient. The process in option 2 is also collected from a blood donor other than the recipient, but the donor is known to the recipient and is usually a family member or friend. Cross-matching significantly enhances compatibility. It does not detect infection.

2. A severely immunocompromised patient requires a blood transfusion. To prevent GVHD, the physician will order:
a. Diphenhydramine hydrochloride (Benadryl).
b. The transfusion to be administered slowly over several hours.
c. Irradiation of the donor blood.
d. Acetaminophen (Tylenol).

Answer C

Rationale: This process eliminates white blood cell functioning, thus, preventing GVHD. Diphenhydramine HCl is an antihistamine. It is use prior to a blood transfusion decreases the likelihood of a transfusion reaction. Option 2 will not prevent GVHD. Use of acetaminophen prevents and treats the common side effects of blood administration caused by the presence of white blood cells in the transfusion product: fever, headache, and chills.

3. A patient who is to receive a blood transfusion asks the nurse what is the most common type of infection he could receive from the transfusion. The nurse teaches him that approximately 1 in 250,000 patients contract:
a. Human immunodeficiency disease (HIV).
b. Hepatitis C infection.
c. Hepatitis B infection.
d. West Nile viral disease.

Answer C

Rationale: Hepatitis B is the most common infection spread via blood transfusion. Donors are screened by a questionnaire that includes symptoms. The donated blood is also tested for infection. The risk of infection with the agents in options 2 and 3 has decreased to approximately 1 in 2 million secondary to donor questioning and donor blood testing. The incidence of West Nile viral transmission is unknown, but donor infection is still relatively rare.

4. A patient with blood type AB, Rh factor positive needs a blood transfusion. The Transfusion Service (blood bank) sends type O, Rh factor negative blood to the unit for the nurse to infuse into this patient. The nurse knows that:
a. This donor blood is incompatible with the patient’s blood.
b. Premedicating the patient with diphenhydramine hydrochloride (Benadryl) and acetaminophen (Tylenol) will prevent any transfusion reactions or side effects.
c. This is a compatible match.
d. The patient is at minimal risk receiving this product since it is the first time he has been transfused with type O, Rh negative blood.

Answer C

Rationale: Type O, Rh negative blood has none of the major antigens and is safely administered to patients of all blood types. It is also known as the universal donor. Premedicating with these agents will not prevent a major transfusion reaction if the blood type and Rh factors of the donor blood are incompatible with the recipient’s blood.

5. The physician orders 250 milliliters of packed red blood cells (RBC) for a patient. This therapy is administered for treatment of:
a. Thrombocytopenia.
b. Anemia.
c. Leukopenia.
d. Hypoalbuminemia.

Answer B

Rationale: A red blood cell transfusion is used to correct anemia in patients in which the low red blood cell count must be rapidly corrected. RBC transfusion will not correct a low platelet count. RBC transfusion will not correct a low white blood cell count. Packed RBCs contain very little plasma and, thus, only a small amount of albumin. This amount will not correct low albumin levels.

NCLEX Questions for Pharmacologies Therapies 2/5

NCLEX Questions for Pharmacologies Therapies 3/5

1. A client in balanced suspension traction for a fractured femur needs to be repositioned toward the head of the bed. During repositioning the nurse should:
a.  Place slight additional tension on the traction cords.
b.  Release the weights and replace immediately after positioning.
c.  Lift the traction and the client during positioning.
d.  Maintain the same degree of traction tension.

Answer: D

Rationale: Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It is not appropriate to increase traction tension or release or lift the traction during repositioning.

2. Which of the following is an abnormal finding in the physical assessment of the musculoskeletal system?
a.  Upper extremities having symmetric, equal muscles
b.  Gait balanced, stride smooth and regular
c.  Flexion, extension, and rotation of the neck
d.  Opposition of three of the four fingers to the thumb

Answer D

Rationale: Opposition of three of the four fingers to the thumb is an abnormal finding in the physical assessment of the musculoskeletal system. A client should be able to do this without difficulty and easy flexibility.

3. Which of the following mobilization devices is usually preferred for the older adult?
a.  Crutches
b.  Cane
c.  Walker
d.  Wheelchair

Answer C

Rationale: Walker-mechanical device with four legs for support this type of device is more supportive and has less expandable energy by the older adult than crutches or a cane. More independence is required than the wheelchair.

4. Nursing diagnosis for the child with a disorder of the musculoskeletal system includes:
a.  High risk for activity intolerance, pain, high risk for injury.
b.  Pain, high risk for weight gain, high risk for abuse.
c.  High risk for altered tissue profusion, high risk for deformity.
d.  Pain, low risk for skin integrity problems; low risk for injury.

Answer A

Rationale: Nursing diagnosis for a child with a disorder of the musculoskeletal system may include: high risk for activity intolerance, pain, divers ional activity deficit, high risk for injury, impaired physical mobility, self-care deficit, body image disturbance, high risk for impaired skin integrity, and altered tissue perfusion peripheral.

5. Which is the traction that is used primarily for children due to the factor infants and toddlers do not have enough body weight?
a.  Milwaukee traction
b.  Open traction
c.  Bryant’s traction
d.  Jones’ traction

Answer C

Rationale: Bryant’s traction is used where the body is its own counterweight; both legs are at 90-degree angles to the bed; buttocks must be slightly off mattress; used with children under 2 years whose weight is under 30 lbs. (14kg); used for fractured femur and dislocated hip.

NCLEX Questions for Basic Care and Comfort  1/4

NCLEX Questions for Basic Care and Comfort  2/4

NCLEX Questions for Basic Care and Comfort  3/4

1. The nurse should have the client use appropriate safety measures with care by:
a. Placing the cane on the affected side.
b. Placing the cane on the opposite affected side.
c. Does not matter which side the cane is on.
d. Choice of cane placement should be the choice of the client.

Answer B.

Rationale: Safety demands that the cane be opposite the affected limb to provide support to the weakened extremity, thus preventing falls.

2. A cane assists the client to walk with greater balance and support. Canes have the following features for safety and support:
a. Feet (four, three, straight), adjustable to allow the elbow to bend slightly, a rubber cap.
b. Feet (straight or two), adjustable to what the client feels is best.
c. Four feet, a rubber tip at both ends.
d. Three feet, enables speed, using two canes.

Answer A.

Rationale: The cane can have four feet (quad), three feet (tripod), or be straight; the length should allow the elbow to bend slightly, and a rubber tip prevents slipping.

3. The standard walker is used when clients:
a. Have poor balance, cannot stand up, have weak arms, and have good hand strength.
b. Have poor balance, broken leg, or amputation.
c. Have poor balance, cardiac problems, and cannot use crutches or cane.
d. Have poor balance, autoimmune diseases, and weak arms.

Answer: C.

Rationale: The use of the walker is used for clients who have balance, cardiac problems, or who cannot use crutches or cane. The client needs to be partial weight bearing and have strength in wrists and arms. The client uses upper body to propel the walker forward.

4. Safety measures for crutches must be in place for a client when the nurse is the primary one for assistance. These safety measures are:
a. To be propel fitted for the client, have rubber tips at the end, and provide for a four-point gait.
b. Properly fitting crutches, education in the appropriate gait, and strength in the arms.
c. Crutches fitting to what the patient chooses, and gait chosen by patient.
d. Have both legs that touch the floor for all gaits.

Answer: B.

Rationale: In addition to the rubber tips on the end of the crutch, the patient needs to know the appropriate gait; arm strengthening exercises are necessary, and it is critical that the patient be fitted for the crutch.

5. The Hydraulic Lift (Hoyer Lift) is used for:
a. The Hydraulic Lift (Hoyer Lift) is used for:
b. All clients who are not able to stand and extremity obese clients.
c. All clients, both old and young in the hospital setting.
d. Not an assistive device for special needs.

Answer B.

Rationale: The Hydraulic Lift is used for safety purposes when a patient is not able to stand or is too heavy for the healthcare workers to lift safely.

NCLEX Questions for Basic Care and Comfort 1/4

NCLEX Questions for Basic Care and Comfort 2/4

NCLEX Questions for Basic Care and Comfort 4/4

1. The orthopedic device made of metal or leather applied to the child’s body, particularly the trunk and lower extremities to support the weight of the body, to correct or prevent deformities, and to prevent involuntary movements in a spastic condition is the:
a. Milwaukee brace worn 23 hours/day, removed once daily for bathing.
b. Jones’ brace worn continuously for 6 weeks.
c. Bryant brace extends from chin to feet.
d. Lee’s brace used to stabilize extremity.

Answer: A

Rationale:The Milwaukee brace is of steel and leather fitted and adapted to the child; used in scoliosis to correct curvature; worn 23 hours/ day, removed once daily for bathing; causes little interference with activity.

2. Nursing care of the child with a brace includes:
a. No more care than usual child care and comfort.
b. Increase observation of the child as for falling, particularly out of bed.
c. Increase calories to 2000+/24 hours.
d. Meticulous skin care and observation and adequate protein and fluid intake.

Answer D

Rationale: Nursing care of the child should include: meticulous observation of skin for breakdown; meticulous care for cleanliness; maintaining dry padding under brace; observing for child’s growth and adjustment of brace; maintaining adequate protein and fluid intake; making sure child experiences minimal discomfort; preventing injury; educating of parents or caretakers about child, care, and comfort.

3. Nursing intervention in a child with a clubfoot (Talipes) includes:
a. Assessment of child with cast/brace, diversional activities; passive exercises to correct position of foot.
b. Assessment of child with cast/brace, let child stand up and walk around bed.
c. Provide for skin care, diversional activities, educational information for cast/brace immobilization device.
d. Provide for comfort, nutrition, and ROM exercises.

Answer C

Rationale: Nursing interventions for a child with a clubfoot (Talipes) should include: constant assessment of child for discomfort, growth, and development; activities for the child and nutritional needs; skin care; no standing or walking during treatment; no ROM exercises to correct foot position; cast care; teaching.

4. Doug, age 3, has a fractured femur and is in Bryant’s traction. To evaluate the correct application of the traction, the nurse should note that:
a. Doug is being continuously and gradually pulled toward bottom of bed.
b. Doug’s buttocks are raised slightly.
c. Doug’s leg is in a 45-degree angle to the bed.
d. Doug can move the unaffected leg freely.

Answer B

Rationale: In Bryant’s traction both legs are in traction at a 90-degree angle, and the child buttocks are raised off the mattress. The child’s weight provides the counter traction. The child should not be pulled toward the bottom of the bed.

5. Ethel, age 14, is in a hip spica cast. To turn her correctly, the nurse should:
a. Use the cross bar.
b. Turn her upper body first and then turn the lower body.
c. Logroll her.
d. Tell her to pull on the trapeze and sit up to help in turning.

Answer: C

Rationale: The client in a hip spica cast should be turned as a unit. The stabilizing bar should not be handled.

NCLEX Questions for Basic Care and Comfort 1/4

NCLEX Questions for Basic Care and Comfort 3/4

NCLEX Questions for Basic Care and Comfort 4/4

1. Which procedure is done at least twice whenever a splint is applied?
a. Elevation of the injured extremity
b. Manual stabilization of the injured extremity
c. Assessment for pulses, sensation, and movement distal to the injury
d. Application of gentle manual traction

Answer C

Rationale: The procedure, which is done at least twice whenever a splint is applied is assessment for pulses, motor function, and sensation (PMS) distal to the injury. After traction is applied, it is not reapplied.

2. The objective of realignment is to:
a. Minimize blood loss and reduce pain.
b. Immobilize the bone ends and adjacent joints.
c. Assist in restoring circulation and to fit the extremity into a splint.
d. Prevent incorrect healing and avoid surgery.

Answer C.

Rationale: The objective of realignment is to assist in restoring circulation and to fit the extremity into a splint.

3. To ensure proper immobilization and increase patient comfort when using a rigid splint:
a. Place the patient on a stretcher before splinting.
b. Place the patient on a long spine board before splinting.
c. Pad the spaces between the body part and the splint.
d. Ensure that the splint conforms to the body curves.

Answer C.

Rationale: To ensure proper immobilization and increase patient comfort when using a rigid splint, pad the spaces between the body part and the splint.

4. The method of splinting is always dictated by:
a. Location of the injury and whether it is open or closed.
b. The severity of the patient’s condition and the priority decision.
c. The number of available rescuers and the type of splints.
d. All of the above.

Answer B.

Rationale: The method of splinting is always dictated by the severity of the patient’s condition and the priority decision.

5. Hazards of improper splinting include:
a. Aggravation of a bone or joint injury.
b. Reduced distal circulation.
c. Delay in transport of patient with life-threatening injury.
d. All of the above.

Answer D

Rationale: Hazards of improper splinting include aggravation of a bone or joint injury, reduced distal circulation, and delay in transport of patient with life-threatening injury.

NCLEX Questions for Basic Care and Comfort 2/4

NCLEX Questions for Basic Care and Comfort 3/4

NCLEX Questions for Basic Care and Comfort 4/4

Answer no. 4
Rationale:
The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client.

2.) A young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client:
1.Verbalizes the role of sexual activity in spread of the disorder.
2.States he will make arrangements to drop his college classes.
3.Acknowledges the need to avoid all contact sports.
4.Says he will avoid close contact with his three-year-old niece.

Answer no.1
Rationale:
The AIDS virus is spread through direct contact with body fluids such as blood and through sexual intercourse.

3.) An infant has just been delivered with a myelomeningocele. The infant is immediately transferred to the nursery. The nurse should place the infant in what position?
1.Semi-sitting with support of an infant seat.
2.Side-lying with his head lower than the rest of his body to promote drainage.
3.Supine to place counterpressure on the defect.
4.Prone to reduce the risk of rupture and infection.

Answer no. 4
Rationale:
Prone is the best position for minimal pressure on the defect. Rupture presents a surgical emergency and all efforts are taken to avoid it.

4.) Which of the following assessments made by the nurse would be essential in understanding behavior of a client with a conversion disorder?
1.Physical symptoms are not under voluntary control.
2.Physical symptoms are under voluntary control but without intent to reduce secondary gain.
3.Physical symptoms are experienced as a means to manipulate others to meet narcissistic needs.
4.Physical symptoms are produced through purposeful means to reduce anxiety and maintain dependency.

Answer no. 1
Rationale:
Conversion disorder is loss or alteration in physical functioning due to psychological causes, but the symptoms are not produced on a conscious level. Symptoms cannot be explained as resulting from an organic physical disorder.

5.) The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?
1.Ask the mother what the child’s name is.
2.Look at the sign above the bed that states the client’s name.
3.Compare the bed number with the bed number of the care plan.
4.Compare the ankle band with the name on the care plan.

Answer no. 4
Rationale:
Making sure that the client’s name is the same as the name on the medication plan is the only safe way to administer medications.