ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
As the nurse cares for a patient with angioedema, differs from urticaria in that angioedema is characterized by which of the following?
Correct Answer: C
Rationale: Step-by-step rationale for choice C: Angioedema differs from urticaria as it involves deeper swelling in the dermis and subcutaneous tissue, leading to a more profound and firm texture. This contrasts with urticaria, which presents as superficial, raised wheals on the skin. Therefore, option C is correct. Summary of other choices: A: Angioedema is not typically associated with intense itching, so it is not more pruritic than urticaria. B: Angioedema does not have small, fluid-filled vesicles like in allergic contact dermatitis. D: Angioedema tends to last longer than urticaria, making this statement incorrect.
Question 2 of 5
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery. Summary of Incorrect Choices: A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function. B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components. D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.
Question 3 of 5
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. When adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Correct Answer: C
Rationale: The correct answer is C: Osteoporosis. Long-term corticosteroid therapy, such as prednisone, is known to cause bone loss and increase the risk of osteoporosis. Corticosteroids inhibit bone formation and increase bone resorption, leading to decreased bone density and increased fracture risk, which can manifest as severe back pain. Incorrect choices: A: Hypertension - Corticosteroids can cause fluid retention and sodium retention, leading to hypertension, but it is not typically associated with severe back pain. B: Muscle wasting - Corticosteroids can lead to muscle weakness, but severe back pain is not typically related to muscle wasting. D: Truncal obesity - Corticosteroids can cause weight gain, especially in the trunk area, but this is not directly responsible for severe back pain.
Question 4 of 5
A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?
Correct Answer: C
Rationale: Rationale: 1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia. 2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake. 3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery. 4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia. Summary: A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia. B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia. D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.
Question 5 of 5
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Correct Answer: D
Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank. Rationale: 1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction. 2. Infuse normal saline solution to maintain adequate hydration and support kidney function. 3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing. Summary of other choices: A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical. B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively. C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.