Exam (elaborations)

NCLEX practice UPDATED ACTUAL Exam Questions and CORRECT Answers

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Uploaded on October 14, 2024
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NCLEX practice UPDATED ACTUAL
Exam Questions and CORRECT Answers
A nurse is assessing the integumentary system of four clients. Which client has the least
chance of a false-positive result while undergoing assessment of capillary refill time?

Client with shock

Client with anemia

Client with epilepsy

Client with peripheral vascular disease - CORRECT ANSWER- ✔✔C

A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill
time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-
positive result). A client with shock has decreased oxygen saturation levels that further
prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood
circulation for clients with anemia, peripheral vascular disease, or diabetes.

While performing a physical assessment of a client, a nurse notices patchy areas with loss of
pigmentation on the skin, hands, and arms. What is the probable etiology for this condition?

Anemia

Pregnancy

Lung disease

Autoimmune disease - CORRECT ANSWER- ✔✔D

Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is
caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced

,amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an
increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an
increased amount of deoxygenated hemoglobin.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-
choice items. If you are uncertain about a question, eliminate the choices that you believe are
wrong and then call on your knowledge, skills, and abilities to choose from the remaining
responses.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as
109o F. Convert this temperature into Celsius and record your number using one decimal
place. - CORRECT ANSWER- ✔✔42.8

Fahrenheit is converted to Celsius by subtracting 32 from the Fahrenheit reading and
multiplying the obtained value by 5/9.
C = (F - 32)(5/9)
C = (109 - 32)(5/9)
C = 42.8

The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is
decreased glucose available for energy and fat is metabolized for energy, resulting in an
increased production of which substance in the urine?

Protein

Glucose

Ketones

Uric acid - CORRECT ANSWER- ✔✔C

As a result of fat metabolism, ketone bodies are formed, and the kidneys attempt to decrease
the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic
acidosis. A low-carbohydrate diet does not cause increased protein, glucose, or uric acid in
the urine.

, The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees
Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The
nurse explains that the rationale for these interventions is to do what?

Promote equalization of osmotic pressures

Prevent hypoxia associated with diaphoresis

Promote integrity of intracerebral neurons

Reduce brain metabolism and limit hypoxia - CORRECT ANSWER- ✔✔D

Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain
metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen.
The integrity of intracerebral neurons and osmotic pressure equalization depend on an
adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of
decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic
medications may cause diaphoresis as vasodilation occurs.

Which question asked by the nurse is an example of open-ended questions?

"How has your health been?"

"Are you feeling any pain now?"

"Do you think the medication is helping you?"

"How would you rate your pain on a scale from 0 to 10?" - CORRECT ANSWER- ✔✔A

What is an example of third spacing in a burn injury?

Blister formation

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Exam (elaborations)

NCLEX practice UPDATED ACTUAL Exam Questions and CORRECT Answers

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