NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

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Question 1 of 5

A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?

Correct Answer: C

Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.

Question 2 of 5

Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?

Correct Answer: D

Rationale: If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder.

Question 3 of 5

The client is admitted with a diagnosis of gestational trophoblastic disease. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Serum hCG levels are markedly elevated in gestational trophoblastic disease and ultrasound reveals a characteristic “snowstorm” pattern or grape-like vesicles. Both tests are essential for diagnosis.

Question 4 of 5

A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:

Correct Answer: C

Rationale: G=3 (current pregnancy), T=1 (term birth), P=1 (preterm birth), A=0 (no abortions), L=2 (living children).

Question 5 of 5

The nurse is caring for a client with a nasogastric tube for decompression. Which action is most appropriate to ensure proper function?

Correct Answer: C

Rationale: Checking nasogastric tube placement (e.g., via pH or aspiration) before feedings or medications ensures the tube is in the stomach, preventing aspiration. Irrigation frequency depends on protocol, clamping may cause reflux, and supine positioning risks aspiration.

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