NCLEX Questions, NCLEX RN Predictor Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

Correct Answer: D

Rationale: Hypercapnia and hypoventilation cause retention of CO2, which increases ICP. Decreasing PaCO2 through hyperventilation reduces vasodilation, thereby decreasing ICP. Increased core body temperature, decreased serum osmolality, and hypo-osmolar fluids would increase ICP.

Question 2 of 5

A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is:

Correct Answer: A

Rationale: Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization.

Question 3 of 5

Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

Correct Answer: B

Rationale: The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. It is important that the infant take in 2-3 full days of milk or formula feedings to preclude a false-negative reading. At 2-3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. The biochemical buildup of serum phenylalanine is detectable after 2-3 days of milk or formula ingestion.

Question 4 of 5

The client is admitted with a suspected myocardial infarction. Which laboratory value is most specific for confirming the diagnosis?

Correct Answer: A

Rationale: Troponin is the most specific and sensitive marker for myocardial infarction, as it is released during cardiac muscle damage and remains elevated for days. CK, myoglobin, and LDH are less specific.

Question 5 of 5

A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

Correct Answer: A

Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.

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