NCLEX-RN
Results Analysis Questions
Extract:
Question 1 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 2 of 5
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure?
Correct Answer: B
Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière's disease. None of the remaining options are prescribed for this disorder.
Question 3 of 5
A 3-week-old infant is brought to the well-baby clinic for a phenylketonuria (PKU) screening test. The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL (60 mmol/L). What is the nurse's priority action?
Correct Answer: A
Rationale: The normal PKU level is 0.8 to 1.8 mg/dL (48 to 109 mmol/L). With early postpartum discharge, screening is often performed when the infant is less than 2 days old because of the concern that the infant will be lost to follow-up. Infants should be rescreened by the time that they are 14 days old if the initial screening was done when the infant was 24 to 48 hours old.
Question 4 of 5
A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating?
Correct Answer: C
Rationale: After a thrombotic stroke, the client often experiences periods of emotional lability, which are characterized by sudden bouts of laughing or crying or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture of the client with this health problem, although it may be difficult for health care personnel and family members to deal with it. The other options are incorrect.
Question 5 of 5
The nurse caring for a child diagnosed with kidney disease is analyzing the child's laboratory results and notes a sodium level of 148 mEq/L (148 mmol/L). On the basis of this finding, which clinical manifestation should the nurse expect to note in the child?
Correct Answer: D
Rationale: Hypernatremia occurs when the sodium level is more than 145 mEq/L (145 mmol/L). Clinical manifestations include intense thirst, oliguria, agitation, restlessness, flushed skin, peripheral and pulmonary edema, dry and sticky mucous membranes, nausea, and vomiting. None of the remaining options are associated with the clinical manifestations of hypernatremia.