NCLEX-PN Test #23 2 — Questions and Answers
Question 1: A nurse is caring for a 4-year-old child admitted with nephrotic syndrome. Which assessment finding is most consistent with this diagnosis?
- Hematuria and hypertension
- Generalized edema and proteinuria (Correct answer)
- Decreased weight and dehydration
- Polyuria and glycosuria
Correct answer: Generalized edema and proteinuria
Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, generalized edema (anasarca), and hyperlipidemia.
Nephrotic syndrome is a kidney disorder characterized by increased glomerular permeability to proteins. The classic features include massive proteinuria (>3.5 g/day in adults), hypoalbuminemia (low serum albumin due to urinary protein loss), generalized edema (anasarca — including periorbital edema most noticeable in the morning, ascites, and peripheral edema), and hyperlipidemia. The edema results from decreased oncotic pressure due to low albumin. In children, minimal change disease is the most common cause. Treatment includes corticosteroids, sodium restriction, albumin infusions for severe cases, and diuretics. Hematuria and hypertension are more characteristic of nephritic syndrome. Weight loss and dehydration are not typical — children often gain weight from fluid retention.
Question 2: A client is prescribed metformin (Glucophage) for type 2 diabetes. Which instruction should the nurse emphasize?
- Take the medication on an empty stomach for better absorption
- Report any muscle pain or dark-colored urine immediately
- Discontinue the medication before any procedure requiring contrast dye (Correct answer)
- Increase the dose if blood sugar remains elevated after one week
Correct answer: Discontinue the medication before any procedure requiring contrast dye
Metformin must be discontinued before procedures involving iodinated contrast dye due to the risk of contrast-induced nephropathy and lactic acidosis.
Metformin is primarily eliminated by the kidneys. When iodinated contrast dye is administered during radiological procedures, it can cause acute kidney injury (contrast-induced nephropathy). If metformin accumulates due to impaired renal function, it can cause lactic acidosis — a rare but potentially fatal complication. Current guidelines recommend holding metformin 48 hours before and after contrast procedures, with resumption only after renal function is confirmed to be adequate. Metformin should be taken with meals, not on an empty stomach, to reduce GI side effects. Muscle pain and dark urine are warning signs for statins (rhabdomyolysis), not metformin. Dose adjustments should only be made by the provider, not the client.
Question 3: A nurse is preparing to administer ear drops to a 2-year-old child. Which technique is correct?
- Pull the pinna up and back
- Pull the pinna down and back (Correct answer)
- Insert the dropper deep into the ear canal
- Have the child sit upright with head tilted forward
Correct answer: Pull the pinna down and back
For children under 3 years old, the pinna is pulled down and back to straighten the ear canal for proper medication instillation.
The technique for administering otic (ear) drops differs between children and adults due to differences in ear canal anatomy. For children under 3 years of age, the pinna (auricle) is pulled down and back because the ear canal is shorter, wider, and more horizontal. For children over 3 years and adults, the pinna is pulled up and back because the ear canal angles downward. This straightens the ear canal to allow medication to flow to the tympanic membrane. The dropper should be directed along the canal wall without inserting it deeply, to avoid injury. The client should lie with the affected ear facing up, and remain in that position for several minutes after instillation to allow the medication to coat the canal.
Question 4: A client who is 28 weeks pregnant reports severe headache, visual disturbances, and epigastric pain. Her blood pressure is 168/110 mmHg. Which condition should the nurse suspect?
- Gestational diabetes
- Preeclampsia with severe features (Correct answer)
- Normal pregnancy discomfort
- Placenta previa
Correct answer: Preeclampsia with severe features
Severe headache, visual changes, epigastric pain, and blood pressure of 168/110 mmHg are classic signs of preeclampsia with severe features.
Preeclampsia with severe features is defined by blood pressure 160/110 mmHg or higher on two occasions, along with signs of end-organ damage: severe persistent headache, visual disturbances (blurred vision, scotomata), epigastric or right upper quadrant pain (liver capsule distension), thrombocytopenia, elevated liver enzymes, renal insufficiency, or pulmonary edema. This is a medical emergency at 28 weeks. Management includes magnesium sulfate for seizure prophylaxis, antihypertensive medications (labetalol, hydralazine), corticosteroids for fetal lung maturity, and consideration of delivery depending on maternal and fetal status. Gestational diabetes presents with hyperglycemia, not hypertension. Placenta previa presents with painless vaginal bleeding. These symptoms are never normal pregnancy discomfort.
Question 5: A nurse is teaching a client about preventing urinary tract infections. Which instruction is most appropriate?
- Limit fluid intake to reduce urinary frequency
- Wipe from back to front after using the toilet
- Urinate after sexual intercourse (Correct answer)
- Use scented feminine hygiene products for cleanliness
Correct answer: Urinate after sexual intercourse
Urinating after sexual intercourse helps flush bacteria from the urethra that may have been introduced during intercourse.
Urinary tract infections (UTIs) are most commonly caused by Escherichia coli bacteria ascending from the perineal area into the urethra. Sexual intercourse can push bacteria toward and into the urethral opening. Urinating after intercourse creates a flushing action that helps remove bacteria before they can ascend into the bladder. Additional prevention strategies include drinking adequate fluids (at least 2-3 liters/day to dilute urine and promote frequent voiding), wiping from front to back (not back to front) to prevent fecal bacteria from reaching the urethra, avoiding irritants such as scented feminine products and bubble baths, wearing cotton underwear, and not delaying urination. Limiting fluid intake would concentrate urine and reduce voiding frequency, both of which increase UTI risk.
Question 6: A nurse is assessing a client receiving morphine sulfate via patient-controlled analgesia (PCA). Which finding requires immediate intervention?
- Pain level of 4/10
- Respiratory rate of 8 breaths per minute (Correct answer)
- Drowsiness after pressing the PCA button
- Blood pressure of 118/72 mmHg
Correct answer: Respiratory rate of 8 breaths per minute
A respiratory rate of 8 breaths per minute indicates respiratory depression, a serious side effect of opioid medications requiring immediate intervention.
Respiratory depression is the most serious and potentially life-threatening adverse effect of opioid medications such as morphine. Normal adult respiratory rate is 12-20 breaths per minute. A respiratory rate of 8 is significantly depressed and requires immediate intervention: stop the PCA infusion, stimulate the client, administer naloxone (Narcan) as ordered, and notify the provider. The nurse should also maintain the airway and provide supplemental oxygen. Mild drowsiness is an expected side effect of opioids and is not dangerous in itself, but excessive sedation is a precursor to respiratory depression. A pain level of 4/10 indicates the medication is providing some relief. A blood pressure of 118/72 is normal. Nurses should assess respiratory rate, depth, and oxygen saturation before and after each PCA dose.
NCLEX-PN Test #23 2
A nurse is caring for a 4-year-old child admitted with nephrotic syndrome.
Which assessment finding is most consistent with this diagnosis?