NCLEX-PN
Free NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, skin hot to touch, sits leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
Correct Answer: D
Rationale: These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.
Question 2 of 5
Which sign might the nurse see in a client with a high ammonia level?
Correct Answer: A
Rationale: High ammonia levels, often due to liver dysfunction, can lead to hepatic encephalopathy, with coma as a severe symptom. The other signs are not directly related to hyperammonemia. Reduction of Risk Potential
Extract:
Which of the following nursing interventions is a priority on a newborn baby?
Question 3 of 5
Wrap the baby in a warm blanket.
Correct Answer: C
Rationale: The Apgar score assesses the newborn's immediate condition, guiding further interventions.
Extract:
Pulsus Paradoxus is best described as
Question 4 of 5
Pulsus Paradoxus is best described as
Correct Answer: B
Rationale: Pulsus paradoxus is an exaggerated drop in systolic BP during inspiration.
Extract:
Question 5 of 5
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage, indicating a rupture of the meninges, which poses a risk of meningitis or other complications in a head injury. This must be reported immediately. Eyelid edema (
A) and minor bleeding (
C) are less urgent, and withdrawal to pain (
D) is consistent with the initial assessment.