NCLEX RN Practice Questions Quizlet - Nurselytic

Correct Answer: C

Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed.

Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor.
Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected.
Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.

Correct Answer: B

Rationale: Acute glomerulonephritis is most commonly caused by the immune response to a prior upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs about 10-14 days after the infection, resulting in scant, dark urine and retention of body fluid. Periorbital edema and hypertension are common signs at diagnosis.

Correct Answer: A

Rationale: In a 28-year-old male presenting with confusion, sweating, and pallor, the most likely cause is hypoglycemia, especially with no mention of trauma or infection.
Therefore, the initial test to be performed should be a blood sugar check to rule out low blood sugar levels. Checking blood sugar levels is crucial in such a scenario as hypoglycemia can lead to altered mental status. A CT scan (choice
B) is not typically the initial test for altered mental status without any focal neurological signs or head trauma. Blood cultures (choice
C) are more relevant in cases suspected of infection, which is not a primary concern in this scenario. Arterial blood gases (choice
D) may be considered later if there are concerns about respiratory status or acid-base disturbances, but in this case, checking the blood sugar level is the most immediate and appropriate action.

Correct Answer: C

Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system.
Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive.
Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive.
Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.

Correct Answer: D

Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (
Choice
A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (
Choice
B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (
Choice
C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.