NCLEX-RN
Results Analysis Questions
Extract:
Question 1 of 5
A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?
Correct Answer: A
Rationale: Prazosin is used to treat hypertension. The side effects of prazosin are dizziness and impotence. The client needs to be instructed to call the primary health care provider if these side effects occur. Holding (skipping) medication will cause an abrupt rise in blood pressure. Option 2 indicates difficulty taking care of oneself. The remaining options indicate client understanding regarding the medication.
Question 2 of 5
A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?
Correct Answer: C
Rationale: The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 mm^3 (20 × 10^9/L). Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the precursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia.
Question 3 of 5
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?
Correct Answer: B
Rationale: Ptosis of the eyelid is caused by pressure on and the dysfunction of cranial nerve III, the oculomotor nerve. The remaining options identify early signs of a deteriorating level of consciousness.
Question 4 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 5 of 5
A client manages peptic ulcer disease (PUD) with excessive amounts of oral antacids. Signs/symptoms of which acid-base imbalance should the nurse assess for?
Correct Answer: B
Rationale: Oral antacids can be effective treatment for PUD when administered properly, but when they are taken in excess they can lead to metabolic alkalosis (a pH of more than 7.45 and a bicarbonate ion [HCO3] level of more than 27 mEq/L [27 mmol/L]). As effective therapy for PUD, antacids bind with the hydrochloric acid (HCl-) of gastric secretions and halt the corrosive action of the HCl-. However, antacids are alkaline substances, and excessive administration can exceed the kidney's ability to clear the excess HCO3, which leads to the accumulation of HCO3, an increased pH, and metabolic alkalosis. Metabolic acidosis occurs when the pH is low and the HCO3 is low; respiratory acidosis occurs when the pH is low and the partial pressure of carbon dioxide (PCO2) is high; and respiratory alkalosis occurs when the pH is high and the PCO2 is low.