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NGN/NCLEX PREP QUESTIONS/RATIONALES ANSWERS LATEST VERSION VERIFIED RATIONALE GRADED A+
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NGN/NCLEX PREP QUESTIONS/RATIONALES ANSWERS LATEST VERSION VERIFIED RATIONALE GRADED A+
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NGN/NCLEX PREP QUESTIONS/RATIONALESANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
A 4-year-old child admited 1 day ago to the pediatric unit is suspected of having periorbital celluli�s of
the right eye with associated impe�go. Which of the current findings would be essen�al to follow up
on?Click to highlight the current finding(s) that would be essen�al to follow up on. Highlight only
finding(s) that require follow-up. To deselect a finding, click the finding again. - ansParameterCurrent8
hours ago24 hours agoBlood pressure92/64 mm Hg98/70 mm Hg99/70 mm HgPulse✓126 beats per
minute120 beats per minute116 beats per minuteRespira�ons18 breaths per minute20 breaths per
minute18 breaths per minuteOral temperature✓38.4° C (101.2° F)37.8° C (100° F)37.6° C (99.9° F)
Laboratory testCurrent24 hours agoWhite blood cell✓18,400/mm3 (18.4 x 103/uL)15,200/mm3 (15.2 x
103/uL)Hemoglobin15.2 g/dL (152 mmol/L)15.0 g/dL (150 mmol/L)Hematocrit38% (0.38)39% (0.39)
Cranial nerve testCurrent24 hours agoCranial nerve II20/20 le� eye20/20 both eyes✓20/40 right
eyeCranial nerve IIIExtraocular movements intact,Extraocular movements intact, no nystagmus✓pain
associated with movements in right eye
2 4 5 9 11
Ra�onale:Periorbital celluli�s is an acute infec�on characterized by pain, erythema, and edema of the
anterior eyelid and �ssue surrounding the eye. The risk with periorbital celluli�s is that it can progress to
orbital celluli�s and can threaten vision. An�bio�cs should be prescribed, and intravenous an�bio�cs
may be required depending on the clinical findings. If bacteremia is suspected, a complete blood count
may be done, and vital signs will be monitored closely. Physical assessment should focus on visual acuity
and extraocular movements. An increase in pulse rate, increase in temperature, increased white blood
cell count, decreased visual acuity, and increased pain on extraocular movements in the affected eye are
all findings that cons�tute a worsening of the condi�on and should be followed up on promptly to
preserve vision.
A child suddenly vomits. The nurse takes the following ac�ons to ensure safety. Select the Ra�onale for
each Nursing Ac�on. - ansNursing Ac�onsRa�onalPosi�on the child upright or on the side.Your Answer:1.
This allows the child to maintain a patent airway.Correct Answer:1. This allows the child to maintain a
patent airway.Perform oral suc�oning.Your Answer:1. This allows the child to maintain a patent
airway.Correct Answer:1. This allows the child to maintain a patent airway.Assess the character and
amount of vomitus.Your Answer:3. This will provide informa�on about possible causes of the vomi�ng
episode.Correct Answer:3. This will provide informa�on about possible causes of the vomi�ng
episode.Assess the force of the vomi�ng.Your Answer:3. This will provide informa�on about possible
causes of the vomi�ng episode.Correct Answer:3. This will provide informa�on about possible causes of
the vomi�ng episode.Monitor intake and output and vital signs.Your Answer:2. This will be helpful in
monitoring for complica�ons of the vomi�ng episode.Correct Answer:2. This will be helpful in
monitoring for complica�ons of the vomi�ng episode.
,NGN/NCLEX PREP QUESTIONS/RATIONALES
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
Ra�onale:If a child suddenly vomits, the nurse must maintain a patent airway. The child should be
posi�oned upright or on the side to prevent aspira�on. Suc�oning equipment should be obtained, kept
at the bedside, and used if needed to assist in maintaining a patent airway. The nurse should check the
character and amount of the vomitus as this will provide informa�on about possible causes of the
vomi�ng episode. The force of the vomi�ng should be assessed because projec�le vomi�ng may indicate
pyloric stenosis or increased intracranial pressure, which are possible causes. The nurse should also
monitor intake and output and vital signs to monitor for the complica�on of dehydra�on.
A client has been diagnosed with chronic kidney disease. The nurse an�cipates specific dietary
prescrip�ons due to the risks associated with chronic kidney disease. Fill in the correct missing
informa�on by choosing from the lists of op�ons in the drop-down menus. - ansThe nurse should note
the client is
Your Answer: On a fluid restric�on
Correct Answer: On a fluid restric�on
because
Your Answer: Of the risk of hypervolemia
Correct Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: Chew gum
Correct Answer: Chew gum
because
Your Answer: it doesn't contribute to hypervolemia
Correct Answer: it doesn't contribute to hypervolemia
Ra�onale:The client with chronic kidney disease may be placed on fluid restric�on because of decreased
renal func�on and glomerular filtra�on rate, resul�ng in fluid volume excess. To allow the kidneys to
rest, decreased fluid consump�on may be indicated. When a client is placed on this restric�on, increased
thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to
promote adherence to the fluid restric�on. These measures include chewing gum or sucking hard candy,
freezing fluids so they take longer to consume, adding lemon juice to allowed water to make it more
refreshing, and gargling with refrigerated mouthwash.
, NGN/NCLEX PREP QUESTIONS/RATIONALES
ANSWERS LATEST VERSION VERIFIED RATIONALE
GRADED A+
A client who is bedbound and incon�nent has been diagnosed with heart failure exacerba�on. The nurse
an�cipates specific prescrip�ons due to the risks associated with heart failure. Fill in the correct missing
informa�on by choosing from the lists of op�ons in the drop-down menus. - ansThe nurse should note
the client is
Your Answer: On a fluid restric�onCorrect Answer: On a fluid restric�on
because
Your Answer: of the risk of hypervolemiaCorrect Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: use lemon swabsCorrect Answer: use lemon swabs
because
Your Answer: it doesn't contribute to hypervolemiaCorrect Answer: it doesn't contribute to
hypervolemia
The nurse notes that in order to effec�vely monitor diure�c therapy, a prescrip�on for
Your Answer: an indwelling urinary catheterCorrect Answer: an indwelling urinary catheter
should be an�cipated because
Your Answer: it allows for monitoring of a therapeu�c effectCorrect Answer: it allows for monitoring of a
therapeu�c effect
Ra�onale:The client with heart failure exacerba�on may be placed on fluid restric�on because of altered
cardiac output and overall cardiac func�on, resul�ng in fluid volume excess. To allow the heart to rest,
decreased fluid consump�on may be indicated. When a client is placed on this restric�on, increased
thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to
promote adherence to the fluid restric�on. These measures include chewing gum or sucking hard candy,
using lemon swabs, freezing fluids so they take longer to consume, adding lemon juice to water to make
it more refreshing, and gargling with refrigerated mouthwash. The client with heart failure exacerba�on
will likely be on diure�c therapy to manage the fluid volume excess. To effec�vely monitor for a
therapeu�c effect, the nurse should an�cipate a prescrip�on for an indwelling urinary catheter if the
client is incon�nent because the excess fluid is excreted by way of the kidneys in the form of urinary
output. An increase in urinary output s
A client with a peripherally inserted central catheter (PICC) in the right upper extremity suddenly exhibits
chest pain, dyspnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC
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