NCLEX-RN
NCLEX RN Client Needs Physiological Adaptation Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is HIV positive and gave birth to a full-term infant. The nurse is teaching the client about infections in HIV-positive infants. Which infection does the nurse understand is the most common opportunistic infection in children and infants with HIV?
Correct Answer: D
Rationale: Pneumocystis jiroveci pneumonia (
D) is the most common opportunistic infection in HIV-positive infants due to immune suppression. Hepatitis C (
A), strep throat (
B), and CMV (
C) are less frequent.
Question 2 of 5
The nurse is seeing a client in the clinic who complains of a sore throat. The client asks for an antibiotic. How should the nurse respond? Select all that apply.
Correct Answer: A,C,E
Rationale: Gargling with saline (
A), explaining viral etiology (
C), and increasing fluids (E) are appropriate. Dehumidifiers (
B) worsen throat dryness, and antibiotics (
D) are not indicated without bacterial confirmation.
Question 3 of 5
The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm X 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?
Correct Answer: D
Rationale: A full-thickness wound with black collagen (eschar) is unstageable (
D) because the depth cannot be assessed. Stage I (
A) is non-blanchable redness, Stage II (
B) is partial thickness, and Stage III (
C) is full thickness without eschar.
Question 4 of 5
The ED nurse receives a client who is bleeding profusely from a gunshot wound. Which action by the nurse will best help this client avoid complications of extreme blood loss?
Correct Answer: B
Rationale: Type O blood (
B) is the universal donor and can be given immediately to prevent complications from blood loss. Type and match (
A) delays treatment, AB+ (
C) is not universal, and family donation (
D) is impractical acutely.
Question 5 of 5
Which assessment finding in a client with chronic kidney disease indicates late-stage symptoms?
Correct Answer: B
Rationale: Oliguria (
B) is a late-stage symptom of CKD due to severe renal impairment. Shortness of breath (
A), edema (
D), and tea-colored urine (
C) occur earlier.