Exam Cram NCLEX RN Practice Questions

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A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

  • A. Prepare the child for an X-ray of the upper airways
  • B. Examine the child's throat
  • C. Collect a sputum specimen
  • D. Notify the healthcare provider of the child's status
Correct Answer: D

Rationale: The correct initial action is to notify the healthcare provider of the child's status. The presenting symptoms described, such as irritability, thick muffled voice, croaking on inspiration, being hot to the touch, sitting leaning forward, tongue protruding, drooling, and suprasternal retractions, are indicative of epiglottitis, a potentially life-threatening condition. Immediate medical attention is crucial in such cases. While preparing for an X-ray or examining the throat may be necessary, the priority is to ensure prompt evaluation and intervention by the healthcare provider. Collecting a sputum specimen is not relevant in this situation and would cause unnecessary delay. Therefore, the nurse should prioritize communication with the healthcare provider to expedite appropriate management and treatment.

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In a 24-year-old woman, the term used to define uterine bleeding in which there is no menstruation is:

  • A. Oligomenorrhea
  • B. Amenorrhea
  • C. Menorrhagia
  • D. Metrorrhagia
Correct Answer: B

Rationale: Amenorrhea is the correct term for the absence of menstrual periods in a woman of childbearing age. It is typically defined as no menstruation for at least three consecutive cycles or six months. Oligomenorrhea refers to infrequent or irregular menstrual periods rather than complete absence. Menorrhagia is characterized by excessive menstrual bleeding, not the absence of menstruation. Metrorrhagia involves irregular, acyclic bleeding between menstrual periods, which is different from the absence of menstruation.

The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response?

  • A. You need to change the child's diet.
  • B. The child probably is infectious again.
  • C. The jaundice may worsen before it resolves.
  • D. You need to call the primary health care provider.
Correct Answer: C

Rationale: The best response for the nurse in this situation is to explain to the mother that jaundice may seem to worsen before it eventually gets better. This is a common occurrence in hepatitis A. Option A about changing the child's diet is irrelevant to the concern raised by the mother and not supported by evidence. Option B suggesting the child is infectious again is incorrect and may cause unnecessary alarm as jaundice does not indicate reinfection. Option D, advising the mother to call the primary health care provider, is premature as the nurse can first provide education and reassurance regarding the expected course of jaundice in hepatitis A.

The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?

  • A. ''I will use a short nipple on the bottle.''
  • B. ''I should avoid using straws for drinking.''
  • C. ''I can give my child the pacifier in 2 weeks.''
  • D. ''I may give my baby food mixed with water.''
Correct Answer: B

Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.

Which of the following is TRUE about shock?

  • A. A patient with severe shock does not always have an abnormally low blood pressure.
  • B. Confusion and deteriorating mentation are indicative of hypotensive shock.
  • C. Patients with compensated shock may not be able to maintain a normal blood pressure.
  • D. A normal blood pressure does not imply that the patient is stable.
Correct Answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

Your patient has been diagnosed with acute bronchitis. You should expect that all of the following will be ordered EXCEPT:

  • A. Increased fluid intake
  • B. Cough medications
  • C. Antibiotics
  • D. Use of a vaporizer
Correct Answer: C

Rationale: In the management of acute bronchitis, antibiotics are not typically prescribed unless there is a confirmed bacterial infection. Acute bronchitis is usually caused by a virus, so antibiotics are not effective in treating it. The primary focus is on symptom management and supportive care. Increased fluid intake helps keep the airway moist and liquefy secretions, aiding in their removal. Cough medications can help relieve cough symptoms. The use of a vaporizer can help moisten the air, making breathing more comfortable for the patient. It is crucial to differentiate between viral and bacterial causes of respiratory infections to avoid unnecessary antibiotic use and prevent antibiotic resistance. Therefore, the correct answer is 'Antibiotics.' Increased fluid intake, cough medications, and the use of a vaporizer are commonly recommended for managing symptoms and improving comfort in patients with acute bronchitis.

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