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Questions 158

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NCLEX RN Nursing Exam Questions

Extract:


Question 1 of 5

A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?

Correct Answer: C

Rationale: Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease.

Question 2 of 5

A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:

Correct Answer: A

Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.

Question 3 of 5

The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?

Correct Answer: B

Rationale: A sweat chloride concentration >60 mEq/L is diagnostic for cystic fibrosis due to defective chloride channels. Potassium levels are not diagnostic, and low chloride is normal.

Question 4 of 5

Which of the following electrolyte imbalances is likely to result in a shortened QT interval?

Correct Answer: A

Rationale: Hypercalcemia shortens the QT interval on an ECG by accelerating cardiac repolarization. Hyponatremia hypomagnesemia and hyperphosphatemia are more likely to prolong the QT interval or have other ECG effects.

Question 5 of 5

The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves?

Correct Answer: B

Rationale: The vagus nerve (X) innervates the pharynx and larynx, contributing to the gag reflex. Absence of the gag reflex suggests vagus nerve injury. Hypoglossal (XII) controls tongue movement, glossopharyngeal (IX) aids taste and swallowing, and facial (VII) controls facial muscles.

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