NCLEX-RN
Results Analysis Questions
Extract:
Question 1 of 5
The nurse is assessing a 39-year-old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180 mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease should the nurse place priority?
Correct Answer: B
Rationale: Hypertension, cigarette smoking, and hyperlipidemia are major risk modifiable factors for coronary artery disease. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 180 mg/dL (4.5 mmol/L) and a blood glucose level of 90 mg/dL (5.14 mmol/L) are within the normal range. The nurse places priority on major risk factors that need modification.
Question 2 of 5
The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?
Correct Answer: C
Rationale: The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction that accompanies this disorder and from the normally decreased ability of the neonate's liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. The white blood cell count is not related to this disorder.
Question 3 of 5
A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?
Correct Answer: D
Rationale: Shock may be classified as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure remains normal. The capillary refill time may be prolonged and more than 2 seconds, and the child may become irritable as a result of increasing hypoxia. The most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock; rather, it is a cause of the fluid and electrolyte imbalance.
Question 4 of 5
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse should determine that which is a priority client problem?
Correct Answer: A
Rationale: The priority client problem in Buck's traction is immobility. Options 3 and 4 may also be appropriate for the client in traction, but immobility presents the greatest risk for the development of complications. Buck's traction is a skin traction, and there are no pin sites.
Question 5 of 5
The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect?
Correct Answer: D
Rationale: Adverse or toxic effects of rifampin include hepatotoxicity, hepatitis, jaundice, blood dyscrasias, Stevens-Johnson syndrome, and antibiotic-related colitis. The nurse monitors for increased liver function, bilirubin, blood urea nitrogen, and uric acid levels because elevations indicate an adverse effect. The normal ALT level is 4 to 36 U/L (4 to 36 U/L). The normal total bilirubin level is 0.3 to 1.0 mg/dL (5.1 to 17 mcmol/L). The normal sedimentation rate is 0 to 30 mm/hour. A normal white blood cell count is 5000 to 10,000 mm^3 (5 to 10 × 10^9/L).