NCLEX-RN
NCLEX RN Exam Review Answers Questions
Question 1 of 5
A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?
Correct Answer: B
Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.
Question 2 of 5
During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.
Correct Answer: A
Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.
Question 3 of 5
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?
Correct Answer: B
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.
Question 4 of 5
When developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis, which intervention should the nurse prioritize?
Correct Answer: A
Rationale: The priority intervention for a 6-year-old child diagnosed with acute glomerulonephritis should be to encourage limited activity and provide safety measures. In glomerulonephritis, children tend to restrict their activities voluntarily due to fatigue during the active phase of the disease. Catheterization for intake and output monitoring may predispose the child to infection and is not the primary intervention. Encouraging the child to talk about feelings related to the illness may not be developmentally appropriate for a 6-year-old; instead, children can express feelings through play. It is important to limit visitors to allow the child to rest and recover rather than encouraging classmates to visit and keep the child informed of school events.
Question 5 of 5
What is a priority problem for a child with severe edema caused by nephrotic syndrome?
Correct Answer: B
Rationale: In nephrotic syndrome, characterized by massive proteinuria, hypoalbuminemia, and edema, a child with severe edema is at high risk for skin breakdown. The priority concern is to prevent skin breakdown by cleaning skin surfaces and ensuring adequate separation with clothing to avoid irritation. The child with nephrotic syndrome is typically anorexic, making consuming more calories or nutrients than necessary not a concern. Risk for constipation and inability to regulate body temperature are not primary issues associated with edema caused by nephrotic syndrome.