NCLEX-RN
Results Analysis Questions
Extract:
Question 1 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 2 of 5
A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?
Correct Answer: C
Rationale: The laboratory manifestations of ITP include the presence of a low platelet count of usually less than 20,000 mm^3 (20 × 10^9/L). Thrombocytopenia is the only laboratory abnormality expected with ITP. If there has been significant blood loss, there is evidence of anemia in the blood cell count. If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, which are the precursors of platelets. Option 4 indicates the bone marrow result that would be found in a child with leukemia.
Question 3 of 5
A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support?
Correct Answer: B
Rationale: Signs and symptoms of cholinergic crisis include nausea, vomiting, abdominal cramping, diarrhea, blurred vision, pallor, facial muscle twitching, pupillary miosis, and hypotension. It is caused by overmedication with cholinergic (anticholinesterase) medications, and it is treated by withholding medications. Myasthenic crisis is an exacerbation of myasthenic symptoms caused by undermedication with anticholinesterase medications. There are no data in the question to support the remaining options.
Question 4 of 5
A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing?
Correct Answer: A
Rationale: Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.
Question 5 of 5
A pregnant client diagnosed with mitral valve prolapse is prescribed anticoagulant therapy during pregnancy. The nurse reviews the client's medical record, expecting to note that which medication therapy is prescribed daily?
Correct Answer: D
Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antenatal, intrapartal, and postpartum periods. Heparin, which does not pass the placental barrier, is a safe anticoagulant therapy during pregnancy, and it would be administered by the subcutaneous route. Warfarin is contraindicated during pregnancy because it passes the placental barrier and causes potential fetal malformations and hemorrhagic disorders. Terbutaline is a medication that is indicated for preterm labor management.