NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
What intervention should the nurse implement while a client is having a grand mal seizure?
Correct Answer: B
Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.
Question 2 of 5
A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit?
Correct Answer: D
Rationale: In a patient with pulmonary edema following a myocardial infarction, the nurse should expect symptoms such as air hunger, anxiety, and agitation. Air hunger refers to the feeling of needing to breathe more deeply or more often. Other symptoms of pulmonary edema can include coughing up blood or bloody froth, orthopnea (difficulty breathing when lying down), and paroxysmal nocturnal dyspnea (sudden awakening with shortness of breath). Slow, deep respirations (
Choice
A) are not typical in pulmonary edema; these patients often exhibit rapid, shallow breathing due to the difficulty in oxygen exchange. Stridor (
Choice
B) is a high-pitched breathing sound often associated with upper airway obstruction, not typically seen in pulmonary edema. Bradycardia (
Choice
C), a slow heart rate, is not a characteristic symptom of pulmonary edema, which is more likely to be associated with tachycardia due to the body's compensatory response to hypoxia and increased workload on the heart.
Question 3 of 5
A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select one that doesn't apply.
Correct Answer: D
Rationale: The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.
Question 4 of 5
Mr. B is recovering from a surgical procedure that was performed four days ago. The nurse's assessment finds this client coughing up rust-colored sputum; his respiratory rate is 28/minute with expiratory grunting, and his lung sounds have coarse crackles on auscultation. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: C
Rationale: In this scenario, the client's presentation of coughing up rust-colored sputum, increased respiratory rate, expiratory grunting, and coarse crackles on lung auscultation suggests the development of pneumonia. Pneumonia is characterized by lung tissue inflammation or infection, often caused by various organisms. Symptoms may include productive cough, dyspnea, and abnormal breath sounds. Tuberculosis (
Choice
A) typically presents with a chronic cough, weight loss, and night sweats and is less likely in this acute post-operative setting. Pulmonary edema (
Choice
B) is characterized by pink, frothy sputum, crackles throughout the lungs, and typically occurs in the context of heart failure. Histoplasmosis (
Choice
D) is a fungal infection that usually presents with flu-like symptoms and is less likely to manifest with the specific respiratory findings described in this case.
Question 5 of 5
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
Correct Answer: D
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (
Choice
A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (
Choice
B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (
Choice
C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.