NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
- A. ''His pediatrician said his kidneys are working well.''
- B. ''I noticed his urine was the color of cola lately.''
- C. ''I'm so glad they didn't find any protein in his urine.''
- D. ''The nurse who admitted my child said his blood pressure was low.''
Correct answer: B
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored, or brown-colored urine, is a classic symptom of glomerulonephritis. Blood urea nitrogen levels and serum creatinine levels may be elevated, indicating that kidney function is compromised. A mild to moderate elevation in protein in the urine is associated with glomerulonephritis. Hypertension is also common because of fluid volume overload secondary to the kidneys not working properly. Therefore, the parent's statement about noticing cola-colored urine aligns with the expected symptom in glomerulonephritis. The other options are less indicative of glomerulonephritis: choice A indicates normal kidney function, choice C mentions absence of protein in the urine (which is not expected in glomerulonephritis), and choice D talks about low blood pressure (hypertension is more common in glomerulonephritis).
2. A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct answer: D
Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems. Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.
3. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- A. The nurse uses a pen pad to communicate with the patient
- B. The nurse provides oral care every 2 hours
- C. The nurse listens for bowel sounds every 4 hours
- D. The nurse suctions as needed and elevates the head of the bed
Correct answer: D
Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.
4. A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?
- A. Infection related to hypertension
- B. Injury related to loss of blood in urine
- C. Excessive fluid volume related to decreased plasma filtration
- D. Retarded growth and development related to a chronic disease
Correct answer: C
Rationale: In acute glomerulonephritis, the child experiences excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume is a primary concern due to the disease process. Hypertension and infection are not directly related to acute glomerulonephritis; therefore, they are not the priority client problems. While hematuria (blood in urine) may occur, it typically does not lead to significant injury that takes precedence over excessive fluid volume. Acute glomerulonephritis is an acute condition, not chronic; therefore, retarded growth and development related to a chronic disease is not the priority issue. With proper management, most children recover completely without long-term growth and development issues.
5. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct answer: B
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
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