Exam (elaborations)
RN NCLEX Questions
Exam of 63 pages for the course NUR 321 - problems with excretion - renal system p at NUR 321 - problems with excretion - renal system p (RN NCLEX Questions)
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RN NCLEX QuestionsA 16-year-old client is admitted to the hospital for acute appendicitis and an
appendectomy is performed. Which nursing intervention is most appropriate to facilitate
normal growth and development postoperatively?
A. Encourage the client to rest and read.
B. Encourage the parents to room in with the client.
C. Allow the family to bring in the client's favorite computer games. D. Allow the client to
interact with others in his or her same age group. - ANS-D
Rationale:
Adolescents often are not sure whether they want their parents with them when they are
hospitalized. Because of the importance of their peer group, separation from friends is a
source of anxiety. Ideally, the members of the peer group will support their ill friend.
Options 1, 2, and 3 isolate the client from the peer group.
A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child
is fearful of the hospitalization. Which nursing intervention should be implemented to
alleviate the child's fears?
A. Encourage the child's parents to stay with the child.
B. Encourage play with other children of the same age.
C. Advise the family to visit only during the scheduled visiting hours.
D. Provide a private room, allowing the child to bring favorite toys from home. - ANS-A
Rationale:
Although the preschooler already may be spending some time away from parents at a
day care center or preschool, illness adds a stressor that makes separation more
difficult. The child may ask repeatedly when parents will be coming for a visit or may
constantly want to call the parents. Options 3 and 4 increase stress related to
separation anxiety. Option 2 is unrelated to the subject of the question and, in addition,
may not be appropriate for a child who may be immunocompromised and at risk for
infection.
A 55-year-old male client confides in the nurse that he is concerned about his sexual
function. What is the nurse's best response?
A. "How often do you have sexual relations?"
,B. "Please share with me more about your concerns."
C. "You are still young and have nothing to be concerned about." D. "You should not
have a decline in testosterone until you are in your 80s." - ANS-B
Rationale:
The nurse needs to establish trust when discussing sexual relationships with men. The
nurse should open the conversation with broad statements to determine the true nature
of the client's concerns. The frequency of intercourse is not a relevant first question to
establish trust. Testosterone declines with the aging process.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? Select all that apply.
A. Diarrhea
B. Black, tarry stools
C. Hyperactive bowel sounds
D. Gray-blue color at the flank
E. Abdominal guarding and tenderness
F. Left upper quadrant pain with radiation to the back - ANS-D, E, F
Rationale:
Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a
result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The
client may demonstrate abdominal guarding and may complain of tenderness with
palpation. The pain associated with acute pancreatitis is often sudden in onset and is
located in the epigastric region or left upper quadrant with radiation to the back. The
other options are incorrect.
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the
first day of her last normal menstrual period was October 19, 2020. Using Näegele's
rule, which expected date of delivery should the nurse document in the client's chart?
A. July 12, 2021
B. July 26, 2021
C. August 12, 2021
D. August 26, 2021 - ANS-B
Accurate use of Näegele's rule requires that the woman have a regular 28-day
menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual
,period, and then add 1 year to that date: first day of the last menstrual period, October
19, 2020; subtract 3 months, July 19, 2020; add 7 days, July 26, 2020; add 1 year, July
26, 2021.
A client arriving at the emergency department has experienced frostbite to the right
hand. Which finding would the nurse note on assessment of the client's hand?
A. A pink, edematous hand
B. Fiery red skin with edema in the nailbeds
C. Black fingertips surrounded by an erythematous rash
D. A white color to the skin, which is insensitive to touch - ANS-D
Rationale:
Assessment findings in frostbite include a white or blue color; the skin will be hard, cold,
and insensitive to touch. As thawing occurs, flushing of the skin, the development of
blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.
A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on
the skin and asks the nurse what to do. The nurse should make which response?
A. "Come to the emergency department."
B. "Apply calamine lotion immediately to the exposed skin areas." C. "Take a shower
immediately, lathering and rinsing several times." D. "It is not necessary to do anything if
you cannot see anything on your skin." - ANS-C
Rationale:
When an individual comes in contact with a poison ivy plant, the sap from the plant
forms an invisible film on the human skin. The client should be instructed to cleanse the
area by showering immediately and to lather the skin several times and rinse each time
in running water. Removing the poison ivy sap will decrease the likelihood of irritation.
Calamine lotion may be one product recommended for use if dermatitis develops. The
client does not need to be seen in the emergency department at this time.
A client had a new colostomy created 2 days earlier and is beginning to pass
malodorous flatus from the stoma. What is the correct interpretation by the nurse?
A. This is a normal, expected event.
B. The client is experiencing early signs of ischemic bowel.
C. The client should not have the nasogastric tube removed.
, D. This indicates inadequate preoperative bowel preparation. - ANS-A
Rationale:
As peristalsis returns following creation of a colostomy, the client begins to pass
malodorous flatus. This indicates returning bowel function and is an expected event.
Within 72 hours of surgery, the client should begin passing stool via the colostomy.
Options 2, 3, and 4 are incorrect interpretations.
A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse
determines that the client has received adequate volume replacement if the blood urea
nitrogen (BUN) level drops to which value?
A. 1.3 mg/dL (1.08 mmol/L)
B. 2.15 mg/dL (5.4 mmol/L)
C. 3.29 mg/dL (10.44 mmol/L)
D. 4.35 mg/dL (12.6 mmol/L) - ANS-B
Rationale:
The normal BUN level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Values of 29 mg/dL (10.44
mmol/L) and 35 mg/dL (12.6 mmol/L) reflect continued dehydration. A value of 3 mg/dL
(1.08 mmol/L) reflects a lower than normal value, which may occur with fluid volume
overload, among other conditions.
A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs
and symptoms indicating a complication of this disorder? Select all that apply.
A. Fever
B. Nausea
C. Lethargy
D. Tremors
E. Confusion
F. Bradycardia - ANS-A, B, D, E
Rationale:
Thyroid storm is an acute and life-threatening complication that occurs in a client with
uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated
temperature (fever), nausea, and tremors. In addition, as the condition progresses, the
client becomes confused. The client is restless and anxious and experiences
tachycardia.
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