4100 NCLEX Proficiency knowledge test Exam
Questions and certified Answers with rationale
2024/2025
A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C),
the blood pressure is elevated, and there is tenderness over the transplanted kidney.
The serum creatinine is rising and urine output is decreased. The x-ray indicates that
the transplanted kidney is enlarged. Based on these assessment findings, the nurse
anticipates which treatment?
1.Antibiotic therapy
2.Peritoneal dialysis
3.Removal of the transplanted kidney
4.Increased immunosuppression therapy - correct answer 4
Rationale:Acute rejection most often occurs within 1 week after transplantation but can
occur any time posttransplantation. Clinical manifestations include fever, malaise,
elevated white blood cell count, acute hypertension, graft tenderness, and
manifestations of deteriorating renal function. Treatment consists of increasing
immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis
cannot be used with a newly transplanted kidney due to the recent surgery. Removal of
the transplanted kidney is indicated with hyperacute rejection, which occurs within 48
hours of the transplant surgery.
The client newly diagnosed with chronic kidney disease recently has begun
hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse
should assess the client during dialysis for which associated manifestations?
1.Hypertension, tachycardia, and fever
2.Hypotension, bradycardia, and hypothermia
3.Restlessness, irritability, and generalized weakness
4.Headache, deteriorating level of consciousness, and twitching - correct answer 4
,Rationale:Disequilibrium syndrome is characterized by headache, mental confusion,
decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure
activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body
during hemodialysis. At the same time, the blood-brain barrier interferes with the
efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells
because of the osmotic gradient, causing increased intracranial pressure and onset of
symptoms. The syndrome most often occurs in clients who are new to dialysis and is
prevented by dialyzing for shorter times or at reduced blood flow rates. Tachycardia and
fever are associated with infection. Generalized weakness is associated with low blood
pressure and anemia. Restlessness and irritability are not associated with disequilibrium
syndrome.
A client presents to the emergency department with upper gastrointestinal bleeding and
is in moderate distress. In planning care, what is the priority nursing action for this
client?
1.Assessment of vital signs
2.Completion of abdominal examination
3.Insertion of the prescribed nasogastric tube
4.Thorough investigation of precipitating events - correct answer 1
Rationale:The priority nursing action is to assess the vital signs. This would provide
information about the amount of blood loss that has occurred and provide a baseline by
which to monitor the progress of treatment. The client may be unable to provide
subjective data until the immediate physical needs are met. Although an abdominal
examination and an assessment of the precipitating events may be necessary, these
actions are not the priority. Insertion of a nasogastric tube is not the priority and will
require a health care provider's prescription; in addition, the vital signs should be
checked before performing this procedure.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for
paralytic ileus. Which piece of assessment data should alert the nurse to this
occurrence?
1.Inability to pass flatus
2.Loss of anal sphincter control
3.Severe, constant pain with rapid onset
,4.Firm, nontender mass palpable at the lower right costal margin - correct answer 1
Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus,
the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical
manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus.
Pain is associated with paralytic ileus, but the pain usually manifests as a more constant
generalized discomfort. Option 4 is the description of the physical finding of liver
enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this
client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or
intestinal obstruction.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative
client approximately 24 hours after gastric surgery. Which finding indicates the need to
notify the health care provider (HCP)?
1.Dark red drainage
2.Dark brown drainage
3.Green-tinged drainage
4.Light yellowish-brown drainage - correct answer 1
Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may
be dark brown to dark red. Later, the drainage should change to a light yellowish-brown
color. The presence of bile may cause a green tinge. The HCP should be notified if dark
red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to
low intermittent suction that is not draining properly. Which action should the nurse take
initially?
1.Call the surgeon to report the problem.
2.Reposition the NG tube to the proper location.
3.Check the suction device to make sure it is working.
4.Irrigate the NG tube with saline to remove the obstruction. - correct answer 3
Rationale:After gastric surgery, the client will have an NG tube in place until bowel
function returns. It is important for the NG tube to drain properly to prevent abdominal
distention and vomiting. The nurse must ensure that the NG tube is attached to suction
, at the level prescribed and that the suction device is working correctly. The tip of the NG
tube may be placed near the suture line. Because of this possibility, the nurse should
never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the
nurse should call the surgeon, who would do this repositioning under fluoroscopy.
The nurse is performing an assessment on a client with acute pancreatitis who was
admitted to the hospital. Which assessment question would most specifically elicit
information regarding the pain that is associated with acute pancreatitis?
1."Does the pain in your stomach radiate to your back?"
2."Does the pain in your lower abdomen radiate to your hip?"
3."Does the pain in your lower abdomen radiate to your groin?"
4."Does the pain in your stomach radiate to your lower middle abdomen?" - correct
answer 1
Rationale:The pain that is associated with acute pancreatitis is often severe, is located
in the epigastric region, and radiates to the back. The remaining options are incorrect
because they are not specific for the pain experienced by the client with pancreatitis.
The nurse is performing an assessment on a client with suspected acute pancreatitis.
Which complaint made by the client supports the diagnosis?
1."I have epigastric pain radiating to my neck."
2."I have severe abdominal pain that is relieved after vomiting."
3."My temperature has been running between 96°F (35.5°C) and 97°F (36.1°C)."
4."i've been experiencing constant, severe abdominal pain that is unrelieved by
vomiting." - correct answer 4
Rationale:Nausea and vomiting are common presenting manifestations of acute
pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by
vomiting. The vomitus characteristically consists of gastric and duodenal contents.
Fever also is a common sign. Epigastric pain radiating to the neck area is not a
characteristic symptom.
