NCLEX-RN
Results Analysis Questions
Question 1 of 5
The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?
Correct Answer: C
Rationale: The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction that accompanies this disorder and from the normally decreased ability of the neonate's liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. The white blood cell count is not related to this disorder.
Question 2 of 5
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).
Question 3 of 5
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
Question 4 of 5
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.
Question 5 of 5
The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect?
Correct Answer: D
Rationale: Adverse or toxic effects of rifampin include hepatotoxicity, hepatitis, jaundice, blood dyscrasias, Stevens-Johnson syndrome, and antibiotic-related colitis. The nurse monitors for increased liver function, bilirubin, blood urea nitrogen, and uric acid levels because elevations indicate an adverse effect. The normal ALT level is 4 to 36 U/L (4 to 36 U/L). The normal total bilirubin level is 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate is 0 to 30 mm/hour. A normal white blood cell count is 5000 to 10,000 mm^3 (5 to 10 × 10^9/L).