NCLEX RN Practice Questions Quizlet

Question 1 of 5

A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?

A. Contact the provider B. Ask the child to write their name on paper C. Ask a coworker about the identification of the child D. Ask the father who is in the room the child's name

Correct Answer: D

Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.

Question 2 of 5

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:

A. Increase fluids that are high in protein B. Restrict fluids C. Force fluids and reassess blood pressure D. Limit fluids to non-caffeine beverages

Correct Answer: D

Rationale: In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability.

Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.

Question 3 of 5

A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

A. Bulging anterior fontanel B. Repeated vomiting C. Signs of sleepiness at 10 PM D. Inability to read short words from a distance of 18 inches

Correct Answer: B

Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.

Question 4 of 5

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select one that doesn't apply.

A. Urine specific gravity of 1.040. B. Urine output of 350 ml in 24 hours. C. Brown ("tea-colored"?) urine. D. Generalized edema.

Correct Answer: D

Rationale: The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.

Question 5 of 5

Which of the following medications taken by the patient is least likely to cause urine discoloration?

A. Sulfasalazine B. Levodopa C. Phenolphthalein D. Aspirin

Correct Answer: D

Rationale: The correct answer is Aspirin. Aspirin is not known to cause urine discoloration. Sulfasalazine is associated with causing orange-yellow discoloration of urine. Levodopa can cause darkening of urine to a brown or black color. Phenolphthalein has been linked to pink or red discoloration of urine.
Therefore, among the options provided, Aspirin is the medication least likely to cause urine discoloration.

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NCLEX-RN

NCLEX-RN