NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Correct Answer: D
Rationale: A temperature of 102.5°F or higher following immunization is considered an adverse reaction and should be reported immediately. This could indicate a more serious systemic response to the vaccine. Irritability, slight edema at the injection site, and local tenderness are common, mild side effects of routine immunizations and do not typically require immediate reporting. Other reactions that should be reported immediately include excessive crying for more than 3 hours, seizure activity, and the presence of tender, swollen, or reddened areas at the injection site.
Question 2 of 5
A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?
Correct Answer: C
Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency.
Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin.
Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency.
Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.
Question 3 of 5
A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
Correct Answer: D
Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems.
Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.
Question 4 of 5
A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
Question 5 of 5
Which response would best assist the chemically impaired client in dealing with issues of guilt?
Correct Answer: B
Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively.
Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions.
Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive.
Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.