NCLEX RN Practice Questions Quizlet - Nurselytic

Correct Answer: D

Rationale: IgG is the only immunoglobulin that can cross the placental barrier, providing passive immunity to the fetus. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are generated after an initial exposure to an antigen, offering long-term protection against microorganisms. IgG antibodies are critical for protecting the fetus as they can be rapidly reproduced upon re-exposure to the same antigen. IgA is primarily found in mucosal areas, IgD is involved in antigen recognition, and IgE is associated with allergic reactions, but they do not provide the same level of protection to the fetus as IgG.

Correct Answer: B

Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.

Correct Answer: D

Rationale: Hypernatremia among elderly clients can result from dehydration and insufficient fluid intake, leading to sodium levels above 145 mEq/L. Common symptoms of hypernatremia include mental status changes, a thick or swollen tongue, excessive thirst, and flushed skin.
Choice A, 'Lack of thirst,' is incorrect as hypernatremia typically presents with excessive thirst.
Choice B, 'Pale skin,' is not a typical symptom of hypernatremia.
Choice C, 'Hypertension,' is not a direct symptom of hypernatremia and is more commonly associated with other conditions like hypertension itself.

Correct Answer: D

Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (
Choice
A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (
Choice
B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (
Choice
C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.

Correct Answer: C

Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (
Choice
A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (
Choice
B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (
Choice
D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.