NCLEX RN Practice Questions Quizlet - Nurselytic

Correct Answer: C

Rationale: In this scenario, the client's presentation of coughing up rust-colored sputum, increased respiratory rate, expiratory grunting, and coarse crackles on lung auscultation suggests the development of pneumonia. Pneumonia is characterized by lung tissue inflammation or infection, often caused by various organisms. Symptoms may include productive cough, dyspnea, and abnormal breath sounds. Tuberculosis (
Choice
A) typically presents with a chronic cough, weight loss, and night sweats and is less likely in this acute post-operative setting. Pulmonary edema (
Choice
B) is characterized by pink, frothy sputum, crackles throughout the lungs, and typically occurs in the context of heart failure. Histoplasmosis (
Choice
D) is a fungal infection that usually presents with flu-like symptoms and is less likely to manifest with the specific respiratory findings described in this case.

Correct Answer: B

Rationale: The correct answer is 'The patient suddenly complains of chest pain and shortness of breath.' Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism"?because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism"?must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed.

Choices A, C, and D describe symptoms that are not typically associated with a pulmonary embolism, making them incorrect.

Correct Answer: D

Rationale: The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.

Correct Answer: B

Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.

Correct Answer: A

Rationale: The correct answer is bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy, with signs such as progressive abdominal pain, fever, chills, and tachycardia indicating advancing peritonitis. Although colonoscopic perforation is rare (0.03% to 0.7% incidence), it can lead to high mortality and morbidity rates. Viral gastroenteritis (
Choice
B) typically presents with symptoms like diarrhea, nausea, vomiting, and abdominal cramps, but it is not the most immediate concern in this scenario. Colon cancer (
Choice
C) and diverticulitis (
Choice
D) are important conditions but are less likely to present acutely after colonoscopy compared to bowel perforation.