Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 158

1. One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:

A) Blood pressure
B) Level of consciousness
C) Skin turgor
D) Fluid intake

2. A child with celiac disease is being discharged from the hospital. The mother demonstrates knowledge of nutritional needs of her child when she is able to state the foods which are included in a:

A) Lactose-restricted diet
B) Gluten-restricted diet
C) Phenylalanine-restricted diet
D) Fat-restricted diet

3. An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:

A) Both lower extremities warm to touch with 2_pedal pulses
B) Both lower extremities cyanotic when placed in a dependent position
C) Decreased or absent pedal pulse in the left leg
D) The left leg warmer to touch than the right leg

4. A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

A) Validate that he is not allergic to iodine or shellfish.
B) Instruct him to start active range of motion of his left leg immediately following the procedure.
C) Inform him that he will not be able to eat or drink anything for 4 hours after the procedure.
D) Inform him that vital signs will be taken every hour for 4 hours after the procedure.

5. A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:

A) Dissolves any clots already formed in the arteries
B) Prevents the conversion of prothrombin to thrombin
C) Interferes with the synthesis of vitamin K-dependent clotting factors
D) Stimulates the manufacturing of platelets

1. Right Answer: B
Explanation: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

2. Right Answer: B
Explanation: (A) A lactose-restricted diet is prescribed for children with lactose intolerance or diarrhea. (B) A gluten-restricted diet is the diet for children with celiac disease. (C)A phenylalaninerestricted diet is prescribed for children with phenylketonuria. (D) A fat-restricted diet is prescribed for children with disorders of the liver, gallbladder, or pancreas.

3. Right Answer: C
Explanation: (A) This statement describes a normal assessment finding of the lower extremities. (B) This assessment finding reflects problems caused by venous insufficiency.(C) Decreased or absentpedal pulses reflect a problem caused by arterial insufficiency. (D) The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation.

4. Right Answer: A
Explanation: (A) Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 612 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. (D) The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.

5. Right Answer: C
Explanation: (A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B)Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.

80% DISCOUNT: NCLEX-RN PRACTICE EXAMS