NCLEX PN Exam Cram - Nurselytic

Questions 58

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Question 1 of 5

Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?

Correct Answer: C

Rationale: Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.

Question 2 of 5

When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?

Correct Answer: D

Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions.

Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.

Question 3 of 5

Which of the following lab values would indicate symptomatic AIDS in the medical chart? (T4 cell count per deciliter)

Correct Answer: D

Rationale: A T4 cell count of less than 200 cells per deciliter indicates symptomatic AIDS. This severe depletion of T4 cells signifies advanced HIV infection and a significantly compromised immune system.

Choices A, B, and C are incorrect because T4 cell counts above 2000, above 1000, or below 500 cells per deciliter, respectively, are not indicative of symptomatic AIDS.

Question 4 of 5

The factor that most determines drug distribution is:

Correct Answer: A

Rationale: The correct answer is 'vascular perfusion of the tissue or organ.' Drug distribution is primarily determined by how well the circulatory system delivers the drug to various tissues and organs. Adequate perfusion ensures proper distribution of the drug throughout the body. While the salt form (choice
B), drug interactions (choice
C), and steady state (choice
D) can influence drug efficacy and metabolism, they are not as crucial as vascular perfusion for the initial distribution of a drug.

Question 5 of 5

A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?

Correct Answer: A

Rationale: Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.

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