Safety and Infection Control NCLEX Part #1 (25 Questions)

NCLEX-Question-1-001

The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:

• A. Is highly sensitive to criticism
• B. Rebels against scheduled activities
• C. Still depends on the parents
• D. Loves to tattle

Correct Answer: A. Is highly sensitive to criticism

Anticipatory guidance is provided by a health care professional to a parent/caregiver in providing an understanding of a child’s development and anticipating their growing needs. In a 6-year-old child, a precarious sense of self causes an overreaction to criticism and a sense of inferiority. Parents can help kids develop a sense of realistic competence by avoiding excessive praise and rewards, encouraging efforts rather than outcomes, and helping kids develop a growth mindset.

• Option B: By age 6, most children love the routine of a schedule. The more children participate in the process, the better they understand and follow the rules. This sense of ownership in the process is key to children this age who are transitioning from accepting outside authority to challenging it.
• Option C: By age 6, most children no longer depend on their parents for daily tasks. During the industry versus inferiority stage, children become capable of performing increasingly complex tasks. As a result, they strive to master new skills. Children who are encouraged and commended by parents and teachers develop a feeling of competence and belief in their skills.
• Option D: Tattling is more common at ages 4 to 5. By age 6, the child wants to make friends and be a friend. Friends and classmates play a role in how children progress through the industry versus inferiority stage. Through proficiency at play and schoolwork, children are able to develop a sense of competence and pride in their abilities.

NCLEX-Question-1-002

While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?

• A. Safety guidelines
• B. Preparation for surgery
• C. Toilet Training
• D. Nursery schools

Correct Answer: A. Safety guidelines

The nurse always should reinforce safety guidelines when teaching parents how to care for their children. By giving anticipatory guidance the nurse can help prevent any accidental injuries. When possible, an age-appropriate diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is the preferred approach to mild or moderate dehydration.

• Option B: Because surgery is not a treatment for gastroenteritis, this topic is inappropriate. The management of acute gastroenteritis is directed at preventing or treating the dehydration that so often accompanies this disease.
• Option C: Toilet training is too early for an 8-month old infant. Most children begin to show signs of readiness for toilet training when they’re between 18 and 24 months old, though some may not be ready until later than that. And boys often start later and take longer to learn to use the potty than girls.
• Option D: For parents of an 8-month-old infant, it is too early to discuss nursery schools. Most preschools start accepting kids around the age of 2.5 to 3 years old, but since every child is different, this isn’t a magic number. Preschool readiness really depends more on developmental factors than chronological age.

NCLEX-Question-1-003

Nurse Betina should begin screening for lead poisoning when a child reaches which age?

• A. 3 months
• B. 12 months
• C. 24 months
• D. 30 months

Correct Answer: B. 12 months

The nurse should start screening a child for lead poisoning at age 12 months and perform repeat screening at age 24, 30, and 36 months. The Advisory Committee on Childhood Lead Poisoning Prevention recommends that all children enrolled in Medicaid be screened for elevated blood lead levels at 12 and 24 months of age or at 36 to 72 months of age if they have not previously been screened.

• Option A: High-risk infants, such as premature infants and formula-fed infants not receiving iron supplementation, should be screened for iron-deficiency anemia at 6 months. Early use and overuse of cow’s milk exacerbates existing causes of iron deficiency in infants. Less often, the problem is due to a severe blood loss or something interfering with the body’s ability to absorb iron, such as a medication the infant is taking or a chronic illness involving the stomach or intestines.
• Option C: The American Academy of Pediatrics (AAP) recommends that a risk assessment be performed for lead exposure at well-child visits at 6 months, 9 months, 12 months, 18 months, 24 months, and at 3, 4, 5, and 6 years of age. A blood lead level test should be done only if the risk assessment comes back positive. 
• Option D: The American Academy of Pediatrics (AAP), as part of an expert committee representing several national healthcare organizations, makes the following recommendation: routine obesity screening of children aged 2 years old or older should include a yearly assessment of weight. BMI changes should be monitored by calculating and plotting BMI on the Centers for Disease Control and Prevention (CDC) growth charts at every healthcare visit.

NCLEX-Question-1-004

When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?

• A. Tachypnea
• B. Shallow respirations
• C. A reduced white blood cell count
• D. A decreased platelet count

Correct Answer: A. Tachypnea

The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. As the body attempts to compensate for worsening acidosis, the respiratory rate increases to reduce the pCO2 and maintain a compensated physiological pH.

• Option B: Initially, the breathing is rapid, but as it worsens, it gradually becomes deep and labored. Extra ketones in the body cause acid to build up in the blood. Because of this, the respiratory system is triggered to start breathing faster. Faster breathing helps expel more carbon dioxide, which is an acidic compound in the blood.
• Option C: An elevation of the white blood cell (WBC) count is a nonspecific finding, but it should prompt consideration of septicemia, which causes lactic acidosis. Severe anemia with compromised oxygen delivery may cause lactic acidosis.
• Option D: Altered platelet counts are not specific signs of metabolic imbalance. Acidosis compromises the clotting process and accelerates fibrinogen consumption with no effect on fibrinogen production, resulting in a deficit in fibrinogen availability.

NCLEX-Question-1-005

After the nurse provides dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching?

• A. “We’ll follow these instructions until our child has completely grown and developed.”
• B. “Well follow these instructions until our child’s symptoms disappear.”
• C. “Our child must maintain these dietary restrictions until adulthood.”
• D. “Our child must maintain these dietary restrictions lifelong.”

Correct Answer: D. “Our child must maintain these dietary restrictions lifelong.”

Celiac disease is an autoimmune reaction to a protein called gluten. A patient with celiac disease must maintain dietary restrictions lifelong to avoid recurrence of clinical manifestations of the disease. A gluten-free diet should be followed by avoiding barley, rye, wheat, oats, and triticale. Once the diagnosis of celiac disease is made, patients need regular follow up to ensure that they are compliant with a gluten-free diet and not developing any complications.

• Option A: It is recommended that all people diagnosed with celiac disease follow a strict gluten-free diet. This adherence is best done under the supervision of specialists, including a dietician. In general, symptoms improve on the gluten-free diet within days to weeks. Non-compliance can be unintentional in an individual who may be still ingesting gluten without realizing it.
• Option B: Currently, the only recommended treatment for celiac disease is the gluten-free diet. This makes a significant impact on the lives of people affected and can be challenging to maintain. There is continuous work on possible non-dietary therapies that enable people with celiac disease to tolerate gluten. One of the main focuses of the research in this area is immune modulators.
• Option C: The prognosis for patients with the correct diagnosis and treatment is good. Unfortunately, compliance with a gluten-free diet is very difficult and relapses are common. Some patients do not respond to a gluten-free diet or corticosteroids; they have a poor quality of life.

NCLEX-Question-1-006

A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expect to find?

• A. Open anterior fontanel and closed posterior fontanel
• B. Closed anterior and posterior fontanels
• C. Closed anterior fontanel and open posterior fontanel
• D. Open anterior and posterior fontanels

Correct Answer: B. Closed anterior and posterior fontanels

By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months. Fontanelles, often referred to as “soft spots,” are one of the most prominent anatomical features of the newborn‘s skull. Fontanelle morphology may vary between infants, but characteristically they are flat and firm.

• Option A: The most common conditions associated with a large anterior fontanelle or a delay in its closure are as listed: Down syndrome, achondroplasia, congenital hypothyroidism, rickets, and elevated intracranial pressures. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will close sooner compared to female infants.
• Option C: Often, the delayed closure of the posterior fontanelle is associated with hydrocephalus or congenital hypothyroidism. Unlike the anterior fontanelle, the posterior fontanelle is triangular and completely closes within about six to eight weeks after birth. On average, the posterior fontanelle is 0.5 cm in Caucasian infants and 0.7 cm in infants of African descent.
• Option D: An elevated thyroid-stimulating hormone level on a newborn screening usually detects congenital hypothyroidism, but an abnormally large anterior fontanel in conjunction with an open posterior fontanel can be an early sign of the disorder. Myxedema and growth deficiency are later signs.

NCLEX-Question-1-007

Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:

• A. Dehydration
• B. Hypovolemic shock
• C. Cerebral edema
• D. Heart failure

Correct Answer: C. Cerebral edema

Due to the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Hyponatremic solutions (e.g. 4% dextrose and one-fifth normal saline), which deliver excess free water, may worsen hyponatremia and increase the risk of cerebral edema, and have no place in the management of meningitis.

• Option A: Fluid overload won’t cause dehydration. Children with meningitis require careful and regular monitoring of clinical signs of hydration state, including signs of overhydration, serum sodium, and laboratory markers of hypovolemia. Under most circumstances, any intravenous fluids given to a child with meningitis should be isonatremic e.g. Plasma-Lyte 148 or 0.9% sodium chloride (normal saline) with additional glucose.
• Option B: Hypovolemic shock would occur with an extreme loss of fluid of blood. Clinical signs of shock or hypovolemia are hypotension, poor peripheral perfusion, cool pale extremities, tachycardia with low volume pulses, high blood lactate or large base deficit. Children with more than one of these signs should be given 10-20ml per kg of normal saline as a bolus.
• Option D: It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Bacterial meningitis can cause overhydration by preventing the body from eliminating fluids the way it should. This can lead to hyponatremia, an electrolyte disturbance in which the sodium concentration in the blood plasma is lower than normal.

NCLEX-Question-1-008

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant?

• A. Encouraging the infant to hold a bottle
• B. Keeping the infant on bed rest to conserve energy
• C. Rotating caregivers to provide more stimulation
• D. Maintaining a consistent, structured environment

Correct Answer: D. Maintaining a consistent, structured environment

Nonorganic failure to thrive refers to decelerated or arrested physical growth and is related with poor developmental and emotional functioning. The nurse caring for an infant with this condition should maintain a consistent, structured environment that provides interaction with the infant to promote growth and development. 

• Option A: Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. Feed the child slowly and carefully in a quiet environment; during feeding, the child might be closely snuggled and gently rocked; it may be necessary to feed the child every 2 to 3 hours initially.
• Option B: The infant should receive social stimulation rather than be confined to bed rest. Attempt to cuddle the child and talk to him or her in a warm, soothing tone and allow for play activities appropriate for the child’s age.
• Option C: The number of caregivers should be minimized to promote consistency of care. While caring for the child, point out to the caregiver the child’s development and responsiveness, noting and praising any positive parenting behaviors the caregiver displays.

NCLEX-Question-1-009

The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to:

• A. Bananas
• B. Color dyes
• C. Kiwifruit
• D. Latex

Correct Answer: D. Latex

Although the exact cause of latex allergy in people with spina bifida is unknown, it is said that continuous exposure to products containing rubber from diagnostic exams, multiple surgeries and bladder and bowl programs may contribute to it. Until better scientific explanations are available to specifically drive prevention and intervention, people with Spina Bifida should continue to avoid skin contact with latex protein in the environment including foods with similar proteins, and avoid inhalation of powder that contains latex.

• Option A: Children, Families, and adults should be aware that caution should be taken regarding what has come to be labeled “latex fruit syndrome.” The protein allergen (example, Hev b 6 hevein) in some latex products makes up a considerable amount of the total protein. This has been shown to have significant cross-reactivity to certain proteins (chitinases) in bananas, avocados, and chestnuts, for example.
• Option B: Some children are allergic to dyes in foods and other products but dyes aren’t a factor in a latex allergy. Hair coloring products contain many ingredients that can irritate the skin and cause allergic reactions. Most cases of allergic contact dermatitis stemming from exposure to hair dye are caused by an ingredient called paraphenylenediamine (PPD).
• Option C: If a child is sensitive to bananas, kiwifruit, and chestnuts, then she’s likely to be allergic to latex because these food items can trigger an allergic reaction. There are at least 25 other fruits that may have some level of cross-reactivity with latex. For example, potatoes, eggplant, and kiwi have been described as potential concerns.

NCLEX-Question-1-010

Cristina, a mother of a 4-year-old child, tells the nurse that her child is a very poor eater. What’s the nurse’s best recommendation for helping the mother increase her child’s nutritional intake?

• A. Use specially designed dishes for children – for example, a plate with the child’s favorite cartoon character
• B. Allow the child to feed herself
• C. Only serve the child’s favorite foods
• D. Allow the child to eat at a small table and chair by herself

Correct Answer: B. Allow the child to feed herself

The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Developmental milestones play a role in a less-than-ravenous appetite. When babies begin walking or running, for example, they often prefer playing and moving around to sitting down and eating. Kids around 2 or 3 years of age also eschew meal time as a way to assert their independence.

• Option A: Special dishes would enhance the primary recommendation. Get creative with the presentation. Make food fun with creative shapes and colours or even fancy little plates and cutlery.
• Option C: The child should be offered new foods and choices, not just served her favorite foods. Keep offering foods they don’t “like.” Kids are often reticent to eat new foods, so offering it regularly helps it become more familiar.
• Option D: Using a small table and chair would also enhance the primary recommendation. If the child knows how to eat with a spoon, don’t get tempted to feed him if he isn’t eating. It may come across as force-feeding and will further lead to a slump in his appetite.

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NCLEX-Question-1-011

Nurse Roy is administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child. What is the smallest amount of glucose that’s considered safe and not caustic to small veins, while also providing adequate TPN?

• A. 5% glucose
• B. 10% glucose
• C. 15% glucose
• D. 17% glucose

Correct Answer: B. 10% glucose

The amount of glucose that’s considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. A dextrose solution of 10% is used initially; if it is tolerated and central access is present, a more concentrated dextrose solution of up to 30 to 35% can be used if needed.

• Option A: Five percent glucose isn’t sufficient nutritional replacement, although it’s safe for peripheral veins. Most patients receive dextrose concentrations of less than 20%. Once the fat and protein calories have been calculated, the balance of calories is provided as intravenous carbohydrate.
• Option C: 15% of glucose through the peripheral veins may put the veins at risk for extravasation. Parenteral nutrition solutions are typically given via central venous catheters due to their high osmolarity and risks with extravasation if delivered peripherally. However, central venous lines are not without risk and consequently infants requiring them are cared for in intensive care settings.
• Option D: Any amount above 10% must be administered via central venous access. Hypertonic dextrose solutions (above approximately 600 mOsmol/liter) may cause thrombosis if infused via a peripheral vein. It is, therefore, advisable to administer such solutions via an intravenous catheter placed in a large central vein, preferably the superior vena cava.

NCLEX-Question-1-012

David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicate that the child is free from pain?

• A. Increased heart rate
• B. Decreased urine output
• C. Increased interest in play
• D. Decreased appetite

Correct Answer: C. Increased interest in play

One of the most valuable clues to pain is a behavior change. A toddler who is pain-free likes to play. In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective measures of pain than self-reports. 

• Option A: An increased heart rate may indicate increased pain. Uncontrolled pain may elevate blood pressure, pulse rate, adrenaline and cortisol serum levels by simultaneously stimulating the sympathetic-autonomic nervous system and release of adrenal hormones.
• Option B: Decreased urine output may signify dehydration. The body’s initial responses to dehydration are thirst to increase water intake and decreased urine output to try to conserve water loss. The urine will become concentrated and more yellow in color. As the level of water loss increases, more symptoms can become apparent.
• Option D: A child in pain is less likely to consume food or fluids. Some behaviors are contrary to other proposed behaviors in a study, for example, reduction of activity or quiet versus jerking, arching back, or kicking. Others are very broad, for example, having disturbed sleep, eating less than usual, being irritable, and playing less than usual. While these behaviors may arouse suspicion concerning the presence of pain, they are nonspecific and associated with a wide diversity of non painful conditions.

NCLEX-Question-1-013

When planning care for a 8-year-old boy with Down syndrome, the nurse should:

• A. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
• B. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
• C. Assess the child’s current developmental level and plan care accordingly
• D. Direct all teaching to the parents because the child can’t understand

Correct Answer: C. Assess the child’s current developmental level and plan care accordingly

Nursing care plans should be planned according to the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. A child with Down syndrome is capable of learning, especially a child with mild limitations.

• Option A: Current practices in providing care to those with Down syndrome include the primary emphasis on the treatment of disease with increased attention allocated to health promotion and protection. Children with Down syndrome have several expected developmental and physical challenges. These include poor physical growth and delayed development with achieving milestones such as gross and fine motor skills, speech, and secondary sex characteristics.
• Option B: With appropriate therapy, the developmental delay may be minimized, and the child’s social quotient may be improved. Such training can provide a foundation for mainstreaming the child with Down syndrome in schools and the community
• Option D: Early intervention programs can improve the academic prognosis for children with Down syndrome. Cognitive function varies tremendously and cannot be predicted at birth. No relationship has been shown between the number of Down syndrome features present in a newborn and later cognitive function.

NCLEX-Question-1-014

Nurse Vincent is teaching the parents of a school-age child. Which teaching topic should take priority?

• A. Explaining normalcy of fears about body integrity
• B. Keeping a night light on to allay fears
• C. Prevent accidents
• D. Encouraging the child to dress without help

Correct Answer: C. Prevent accidents

Accidents are the major cause of death and disability during the school-age years. Therefore, accident prevention should take priority when teaching parents of school-age children. In 2016, there were 20,360 deaths among children and adolescents in the United States. More than 60% resulted from injury-related causes, which included 6 of the 10 leading causes of death. 

• Option A: Preschool (not school-age) children have fears concerning body integrity. Help prepare children for situations they may find frightening. Read a story about going to the dentist, or ask a firefighter to visit the school and allow children to handle the equipment while you stand nearby for reassurance.
• Option B: Preschool (not school-age) children are afraid of the dark. At about 3 ½, children often develop a variety of insecurities and physical ways of showing them. Fear of the dark and nightmares are common and may last quite a while. There is so much going on in the world of a 3-year-old-so much mastery, so many things they’ve already become familiar with. At the same time, however, children this age may be disturbed by characteristics they find unfamiliar.
• Option D: Preschool (not school-age) children should be encouraged to dress without help (with the exception of tying shoes). Preschoolers revel in their newfound independence. Being able to make such choices is a natural part of growing up, and gives threes and fours an exciting sense of themselves as powerful people.

NCLEX-Question-1-015

The nurse is finishing her shift on the pediatric unit. Because her shift is ending, which intervention takes top priority?

• A. Restocking the bedside supplies needed for a dressing change on the upcoming shift
• B. Documenting the care provided during her shift
• C. Emptying the trash cans in the assigned client room
• D. Changing the linens on the clients’ beds

Correct Answer: B. Documenting the care provided during her shift

Documentation should take top priority. Documentation is the only way the nurse can legally claim that interventions were performed. An end-of-shift report allows nurses to understand where their patients stand in regard to recovery by providing a picture of a patient’s improvement or decline over the last several hours. By knowing what has previously occurred in a patient’s treatment plan, nurses can proceed with the right steps to contribute to positive outcomes. Pertinent patient information to support the multidisciplinary team to deliver great care.

• Option A: Wrapping up a nursing shift is similar to starting one. At the end of their workday, nurses often conduct their final patient rounds to check on any last-minute needs, conduct final med passes, and assist patients with their final meals if the shift ends around dinnertime.
• Option C: Emptying trash cans can be done by the nurse but it is not mandatory. The nurse may make sure a policy on waste management is familiar to all staff. This includes ensuring that contaminated waste is disposed of correctly. Colour coding of different types of waste is used widely and it is important not to mix up the waste that is dealt with in different ways.
• Option D: This option would be appreciated by the nurses on the oncoming shift but aren’t mandatory and doesn’t take priority over documentation. Soiled linen is infectious to the patient. If a patient is unable to move or leave the bed, the nurse will need to change the bedsheets while the patient is occupied in bed.

NCLEX-Question-1-016

Nurse Harry is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should:

• A. Perform only two-person CPR
• B. Deliver 12 breaths/minute
• C. Place two fingers on the sternum, press down about 1.5 inches deep
• D. Use the heel of one hand for sternal compressions

Correct Answer: D. Use the heel of one hand for sternal compressions

The nurse should use the heel of one hand at the center of the chest, then place the heel of the other hand on top of the first hand and lace fingers together and give 30 compressions that are about 2 inches deep. For a child, compress the chest at least one-third the depth of the chest. This may be less than two inches for small children but will be approximately two inches for larger children (4-5 cm).

• Option A: For a small child, two-person rescue may be inappropriate. If the child does not respond and is not breathing (or if only gasping), have the second rescuer call 911/EMS and get an AED.
• Option B: For children, the compression to breath ratio is 15:2 for all age groups. If you cannot feel a pulse (or if you are unsure), begin CPR by doing 15 compressions followed by two breaths. If you can feel a pulse but the pulse rate is less than 60 beats per minute, you should begin CPR. This rate is too slow for a child.
• Option C: The nurse uses 2 fingers to give 30 quick compressions that are each about 1.5 inches deep appropriate for infants. Place 2 fingers just below that line on the breastbone and push down hard on the breastbone 1½ inches toward the backbone. Let the chest come back to its normal position after each compression. Compressions are done fast at a rate of 100 per minute.

NCLEX-Question-1-017

A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

• A. Obtaining history information from the parents
• B. Administering acetaminophen (Tylenol)
• C. Instituting droplet precautions
• D. Orienting the parents to the pediatric unit

Correct Answer: C. Instituting droplet precautions

Instituting droplet precautions by providing a private room and wearing a mask, gloves, and gown for all those who will interact with the child is a priority for a newly admitted patient with meningococcal meningitis until an appropriate antibiotic regimen has been given for 24 hours. Based on experience with military recruits, the nasopharyngeal carrier state is the primary factor for the transmission and development of meningitis.

• Option A: Obtaining history information doesn’t take priority. The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration.
• Option B: Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Antibiotic dose should be given as soon as meningitis is suspected and should not be delayed awaiting confirmatory studies. Lumbar puncture is performed as soon as possible as parenteral antibiotic therapy clears out meningococci from CSF in less than six hours.
• Option D: Orienting the parents to the unit doesn’t take priority. Meningococcal meningitis is a medical emergency presenting with severe sepsis syndrome, fever, petechiae, and ecchymosis requiring prompt resuscitation and antibiotic administration.

NCLEX-Question-1-018

Shane tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is:

• A. Developmental level of the child’s peers
• B. Consistency in approach
• C. The mother’s positive attitude
• D. Developmental readiness of the child

Correct Answer: D. Developmental readiness of the child

There is no right age to toilet train a child. Readiness to begin toilet training depends on the individual child. If the child isn’t developmentally ready, the child and parent will become frustrated. Signs of potty training readiness include pulling at a wet or dirty diaper, awakening dry from a nap, hiding to go or going to an area to pee or poop, and having predictable bowel movements.

• Option A: Developmental levels of children are individualized and comparison to peers isn’t useful. In general, starting before age 2 (24 months) is not recommended. The readiness skills and physical development the child needs occur between age 18 months and 2.5 years.
• Option B: Consistency is important once toilet training has already started. Each child has his or her own style of behavior, which is called temperament. In planning your approach to toilet training, it is important to consider your child’s temperament.
• Option C: The mother’s positive attitude is important when the child is ready. The parents should try not to feel pressured to toilet train the child. If the parents are feeling pressured to train the child because of caregiver considerations or family members’ views, their anxiety about toilet training can create anxiety in the child.

NCLEX-Question-1-019

An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?

• A. The nurse-manager
• B. The registered nurse caring for the infant
• C. The social worker who placed the infant in the foster home
• D. The foster mother 

Correct Answer: D. The foster mother

When children are minors and aren’t emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. Foster carers do not have parental responsibility but should have delegated authority/decision-making power for consent for most treatments.

• Option A: The nurse manager has no legal right to give consent in this scenario. Each situation is different but as a rule foster carers should be able to sign consents for routine medicals, eye and sight tests, and routine dental examinations.
• Option B: The nurse has no legal right to give consent in this scenario. Foster carers should be given delegated authority wherever possible to consent to immunizations and the placement plan should clarify who can give consent in a medical emergency.
• Option C: The social workers have no legal rights to give consent in this scenario. It is important that foster carers understand their responsibilities around health care, medical treatment, and consent so that they can support a child’s physical, mental, and emotional health.

NCLEX-Question-1-020

A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:

• A. Prevent uric acid from precipitating in the ureters
• B. Enhance the production of uric acid to ensure adequate excretion of urine
• C. Prevent metabolic breakdown of xanthine to uric acid
• D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow

Correct Answer: C. Prevent metabolic breakdown of xanthine to uric acid

The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. These clients can have increased uric acid levels due to release of uric acid from the dying cancer cells.

• Option A: Allopurinol and oxypurinol both inhibit xanthine oxidase, an enzyme in the purine catabolism pathway that converts hypoxanthine to xanthine to uric acid. Allopurinol undergoes metabolism in the liver, where it transforms into its pharmacologically active metabolite, oxypurinol.
• Option B: Urate production is accelerated by purine rich diets, endogenous purine production, and high cell breakdown, and it is responsible for a minority of cases of hyperuricemia. Foods rich in purine include all meats but specifically organ meats (kidneys, liver, “sweet bread”), game meats and some seafood (anchovies, herring, scallops). 
• Option D: Allopurinol doesn’t act in the manner described in this option. To prevent tumor lysis syndrome, allopurinol shall be initiated 2 to 3 days before starting chemotherapy and continued until 3 to 7 days after chemotherapy.

NCLEX-Question-1-021

A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?

• A. Gloves
• B. Gown and gloves
• C. Gown, gloves, and mask
• D. Gown, gloves, mask, and eye goggles or eye shield

Correct Answer: D. Gown, gloves, mask, and eye goggles or eye shield

The transmission of SARS isn’t fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any health care worker providing care for a client with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.

• Option A: For level 1 or standard infection control precaution wherein there is no suspected or known infectious agent, disposable gloves and disposable apron may be used. If there is a danger or risk of spraying or splashing, eye and face protection should be considered.
• Option B: Level 2 or direct/indirect contact precautions require the use of a disposable gown (which is fluid-resistant) and disposable gloves. This is used when there is a suspected or confirmed infectious agent spread by direct or indirect contact.
• Option C: Level 2 droplet precautions occur when there is a suspected or confirmed infectious agent spread by droplet route/ Personal protective equipment should include a disposable gown which is fluid-resistant, disposable gloves, and fluid-resistant surgical face mask and goggles.

NCLEX-Question-1-022

A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the result be evaluated?

• A. Immediately
• B. Within 24 hours
• C. In 48 to 72 hours
• D. After 5 days

Correct Answer: C. In 48 to 72 hours

Tuberculin skin tests of delayed hypersensitivity. If the test results are positive, a reaction should appear in 48 to 72 hours. Two visits are required in this test. First visit to get the test administered, and the second visit to get the reading of the test after 48 to 72 hours of test placement.

• Option A: Immediately after the test is  too soon to observe a reaction. The results of this test are interpreted by measuring the hypersensitivity reaction (delayed-type hypersensitivity) to tuberculin purified protein derivative, derived from Mycobacterium tuberculosis.
• Option B: Within 24 hours is too soon to observe a reaction. The peak of the induration reaction occurs after 24 hours of the test injection. Induration of the skin at the injection site occurs secondary to cell infiltration. 
• Option D: Waiting more than 5 days to evaluate the test is too long because any reaction may no longer be visible. It takes about 6 to 8 weeks after exposure to the bacteria for the PPD test to be positive.

NCLEX-Question-1-023

Nurse Oliver is teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?

• A. Whole milk and baby food
• B. Iron-rich formula only
• C. Skim milk and baby food
• D. Iron-rich formula and baby food

Correct Answer: B. Iron-rich formula only

The American Academy of Pediatrics recommends that infants at age 5 months receive iron-rich formula and that they shouldn’t receive solid food – even baby food – until age 6 months. All children need iron. It is important at all stages of a child’s development. Babies fed only breast milk, only formula, or a mix of breast milk and formula have different needs when it comes to iron.

• Option A: The Academy doesn’t recommend whole milk until age 12 months. Once the infant is past one year old, they may be given whole cow’s milk or reduced-fat (2%) milk, provided they have a balanced diet of solid foods (cereals, vegetables, fruits, and meats). But limit his intake of milk to 2 cups (about 16 ounces) per day or less.
• Option C: Skim milk is only appropriate until after age 2 years. Babies and toddlers need fat in their diets for a variety of reasons, including healthy brain development. So it’s usually recommended that kids 1 to 2 years old drink whole milk. Then, if their growth is steady, it’s safe to switch to low-fat or nonfat (skim) milk.
• Option D: A child can start eating solid foods at about 6 months old. First foods that need to be introduced should be soft and easy to swallow such as mashed vegetables or porridge. Make sure to choose foods that contain iron. Iron found in foods comes in two forms: heme and nonheme iron.

NCLEX-Question-1-024

Gracie, the mother of a 3-month-old infant, calls the clinic and states that her child has a diaper rash. What should the nurse advise?

• A. “Leave the diaper off while the infant sleeps.”
• B. “Use baby wipes with each diaper change.”
• C. “Switch to cloth diapers until the rash is gone”
• D. “Offer extra fluids to the infant until the rash improves.”

Correct Answer: A. “Leave the diaper off while the infant sleeps.”

Leaving the diaper off while the infant sleeps helps to promote air circulation to the area, improving the condition. Air out the infant’s skin by letting him or her go without a diaper and ointment for short periods of time, perhaps three times a day for 10 minutes each time, such as during naps.

• Option B: Baby wipes contain alcohol, which may worsen the condition. Moist washcloths, cotton balls and baby wipes can aid in cleaning the skin, but be gentle. Don’t use wipes with alcohol or fragrance.
• Option C: Switching to cloth diapers isn’t necessary; in fact, that may make the rash worse. The best way to keep the infant’s diaper area clean and dry is by changing diapers immediately after they are wet or soiled. Until the rash is better, this may mean getting up during the night to change the diaper.
• Option D: Extra fluids won’t make the rash better. When possible, let the infant go without a diaper. Exposing skin to air is a natural and gentle way to let it dry. To avoid messy accidents, try laying the infant on a large towel and engage in some playtime while he or she is bare-bottomed.

NCLEX-Question-1-025

Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?

• A. Call an ambulance immediately
• B. Administer ipecac syrup
• C. Punish the child for being bad
• D. Call the poison control center

Correct Answer: D. Call the poison control center

Before interviewing in any way, the parents should call the poison control center for specific directions to avoid death or permanent disability associated with ingestion of poisonous substances. If there is suspicion that a child has been exposed to a poison – whether swallowed, spill on the skin, splashed in the eye, or inhaled – or if a child has been given the wrong medicine or wrong dose of medicine, the parents should phone the Poisons Information Center immediately.

• Option A: The parents may have to call an ambulance after calling the poison control center. The Poisons Information Centre will get a brief history from the parents about what happened and will provide the appropriate advice. Many poisoning exposures in children are mild and can be safely managed at home – staff from the Poisons Information Centre will tell them what to do.
• Option B: Ipecac syrup is no longer used and is recommended by the poison control center. Ipecac has been found to have minimal health benefits and is ultimately ineffective at purging the body of poisonous substances. It was initially discontinued due to production costs and lack of raw materials.
• Option C: Punishment for being bad isn’t appropriate because the parents are responsible for making the environment safe. The best protection against poisoning is to make sure that children do not have access to any poisons or medicines.