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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed?

Correct Answer: A

Rationale: MMR. Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella (MMR) is a live virus vaccine, and its administration should be delayed to ensure the body’s ability to form antibodies.

Question 2 of 5

For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant?

Correct Answer: C

Rationale: Appendicitis typically causes tenderness in the lower-right quadrant (McBurney's point) due to the appendix's anatomical location. Physiological Adaptation

Question 3 of 5

With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?

Correct Answer: A

Rationale: This client is the most stable and has a chronic condition. Tylenol intoxication requires at least 3 to 4 days of intensive observation for the risk of hepatic failure. The other clients would be considered unstable.

Question 4 of 5

Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguinous drainage on the dressing. The most appropriate intervention is to:

Correct Answer: C

Rationale: Serosanguinous drainage is normal post-cholecystectomy; reinforcing the dressing is appropriate to manage it. Changing the dressing risks infection, and a binder may obscure assessment. Basic Care and Comfort

Extract:

A patient with a tentative diagnosis of cholecystitis is discharged from the emergency room with instructions to make an appointment for a more definitive diagnosis workup.


Question 5 of 5

The recommendation that would produce the most valuable diagnostic information would be:

Correct Answer: A

Rationale: A pain journal helps identify triggers and patterns, aiding cholecystitis diagnosis.

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