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Questions 227

NCLEX-PN

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Extract:

Which of the following individuals is at greatest risk for experiencing cerebral vascular accident?


Question 1 of 5

A 50-year-old African-American male with history of hypertension.

Correct Answer: A

Rationale: This patient has multiple risk factors for CVA: African-American race, male gender, age, and hypertension.

Extract:


Question 2 of 5

Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings?

Correct Answer: B

Rationale: Excessive fluoride intake. The described findings are indicative of fluorosis, associated with repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.

Extract:

A patient with complaints of loss of peripheral vision


Question 3 of 5

A patient with complaints of loss of peripheral vision is suspected to have

Correct Answer: C

Rationale: Glaucoma causes peripheral vision loss due to increased intraocular pressure.

Extract:


Question 4 of 5

An adult asks the nurse why she must have her skin shaved prior to surgery. What is the best nursing response? Reducing the hair by shaving:

Correct Answer: A

Rationale: Shaving reduces infection risk by removing hair, which can harbor bacteria, the primary rationale for preoperative skin preparation.

Question 5 of 5

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Correct Answer: D

Rationale: The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia.
Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.

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