NCLEX RN Simulated Exam Test Bank - Nurselytic

Correct Answer: C

Rationale: The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract.
Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi.
Choice B is incorrect as rhonchi can be heard in individuals beyond infancy.
Choice D is incorrect as rales can be present in patients of various age groups, not just infants.

Correct Answer: D

Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.

Correct Answer: A

Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.

Correct Answer: C

Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses.
Choice A is a closed-ended question since it seeks a specific time for the medication intake.
Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response.
Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.

Correct Answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients.
Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention.
Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention.
Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention.
Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.