2022-12-04 NCLEX Exam Question: The nurse is assigned to care for an infant with the diagnosis of bladder exstrophy.
To best protect the exposed bladder tissue, the nurse should plan which intervention?
Select an Answer: Cover the bladder with a nonadhesive plastic wrap. Cover the bladder with a petroleum jelly gauze. Apply a sterile water dressing on the tissue. Use dry sterile gauze to keep the tissue dry.
Rationale:
In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. The best way to do this is to cover the bladder with a nonadhesive plastic wrap.
The other answer choices are not good options. They all can lead to damage of the mucosa.
2022-12-03 NCLEX Exam Question: A child is being admitted to the hospital for suspected Hirschsprung's disease.
The nurse reviews the child's chart and looks at the assessment findings, knowing that which sign most likely led the mother to bring the child to the hospital in the first place?
Select an Answer: diarrhea foul-smelling, ribbon-like stools vomiting poor feeding
Rationale:
Hirschsprung's disease is a congenital aganglionosis or aganglionic megacolon. It results from the absence of ganglion cells in the rectum and other areas of the affected intestine. There is chronic constipation beginning in the first month and resulting in pellet-like or ribbon-like, foul-smelling stools.
The other options are not associated specifically with this disease.
2022-12-02 NCLEX Exam Question: The nurse taking care of a 2-year-old child suspects that the child may have strabismus.
Which observation made by the nurse suggests the presence of the condition?
Select an Answer: The child tilts the head to hear. The child tilts the head to see. The child cannot hear the nurse's commands. The child does not speak when spoken to.
Rationale:
Strabismus is a condition where the eyes are not aligned due to a lack of coordination of the extraocular muscles.
Observational/assessment findings that may suggest strabismus are:
Complaints of frequent headaches
Squinting
Tilting the head to see
Crossed eyes
Closing one eye to see
Diplopia
Photophobia
Loss of binocular vision
2022-12-01 NCLEX Exam Question: The school nurse agrees with the federal regulations for mandatory immunizations for children. The nurse is aware that this will prevent diseases and the spread of diseases to others.
Which of the following ethical frameworks is the nurse using?
Select an Answer: Utilitarianism Philosophy Deontology Ethics of Care
Rationale:
Utilitarianism is a system of ethics that focuses on the outcome of the greatest good for the greatest number of people.
Deontology does not look to consequences of actions but on characteristics such as fidelity and justice.
The role of feelings is emphasized in the ethics of care.
Philosophy is not an ethical framework.
2022-11-30 NCLEX Exam Question: When assessing a patient with allergic rhinitis, upon inspection of the nasal mucosa, the nurse might find its appearance:
Select an Answer: pale, blueish gray, and engorged. dry and cracked. red and flaky. red and swollen.
Rationale:
When assessing nasal mucosa, inspect for color, swelling, drainage, and bleeding.
The mucus membrane of the nose normally appears redder than the oral mucosa, but is pale, engorged, and bluish gray in patients with allergic rhinitis.
