NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. When reading a lab report, you notice that a patient's sample is described as having anisocytosis. Which of the following most accurately describes the patient's condition?
- A. The patient has an abnormal condition of skin cells.
- B. The patient's red blood cells vary in size.
- C. The patient has a high level of fat cells and is obese.
- D. The patient's cells are indicative of necrosis.
Correct answer: B
Rationale: Anisocytosis is a term that indicates variation in the size of red blood cells. When a patient is described as having anisocytosis, it means their red blood cells exhibit differences in size. This condition can be detected in blood samples and may indicate underlying blood disorders. The other choices are incorrect: Choice A refers to a skin cell condition, Choice C relates to obesity and fat cells, and Choice D suggests necrosis, none of which are associated with anisocytosis or red blood cell abnormalities. It is important to recognize specific terms like anisocytosis in laboratory reports to understand the potential implications for the patient's health.
2. What is a priority problem for a child with severe edema caused by nephrotic syndrome?
- A. Risk for constipation
- B. Risk for skin breakdown
- C. Inability to regulate body temperature
- D. Consuming more calories or nutrients than the body requires
Correct answer: B
Rationale: In nephrotic syndrome, characterized by massive proteinuria, hypoalbuminemia, and edema, a child with severe edema is at high risk for skin breakdown. The priority concern is to prevent skin breakdown by cleaning skin surfaces and ensuring adequate separation with clothing to avoid irritation. The child with nephrotic syndrome is typically anorexic, making consuming more calories or nutrients than necessary not a concern. Risk for constipation and inability to regulate body temperature are not primary issues associated with edema caused by nephrotic syndrome.
3. A healthcare provider is assessing vital signs in pediatric patients. Which of the following vital signs is abnormal?
- A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg
- B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
- C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg
- D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
Correct answer: B
Rationale: The normal range of vital signs for pediatric patients varies with age. For 11 to 14-year-olds, the normal vital sign ranges are: Heart rate: 60-105 BPM; Respiratory rate: 12-20 RPM; Blood pressure: Systolic 85-120 mmHg, Diastolic 55-80 mmHg. The 13-year-old female in choice B has a diastolic blood pressure below the normal range, indicating hypotension. Additionally, her heart rate is at the upper limit of normal, and her respiratory rate is within normal limits. Choices A, C, and D all fall within the normal ranges for vital signs in pediatric patients.
4. A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?
- A. Administer Lorazepam (Ativan)
- B. Turn the patient to his/her side
- C. Call the physician
- D. Suction the patient
Correct answer: B
Rationale: The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.
5. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
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