NCLEX Questions, ATI NCLEX-RN Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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ATI NCLEX-RN Practice Questions Questions

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Question 1 of 5

A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction?

Correct Answer: B

Rationale: Because the left atrial pressure is greater than right atrial pressure, oxygenated blood flows from the left to the right atria. Because of the risk of pulmonary obstructive diseases and congestive heart failure later in life, surgery is usually performed between age 4 and 6 years, with essentially no operative mortality or postoperative complications. Many ventricular septal defects close spontaneously (20-60%) as a result of growth and proliferation of the muscular septum or formation of a membrane across the opening. This management is usually recommended with children with mild pulmonary stenosis.

Question 2 of 5

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?

Correct Answer: B

Rationale: Adding baby oil to bath water moisturizes skin, relieving pruritus in hepatitis. Warm showers (
A) and hot rinses (
D) may worsen itching, and powder (
C) can dry skin further.

Question 3 of 5

A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, "I don't believe the doctor; I think he has me confused with another patient."

Correct Answer: A

Rationale: The client's statement reflects denial, the first stage of Kubler-Ross' model, where patients refuse to accept a terminal prognosis. Anger (
B), depression (
C), and bargaining (
D) involve different emotional responses.

Question 4 of 5

A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

Correct Answer: B

Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.

Question 5 of 5

A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

Correct Answer: B

Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.

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