NCLEX-PN Test #6 — Questions and Answers
Question 1: The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- Reluctance to swallow
- Drooling of blood-tinged saliva
- An axillary temperature of 99°F
- Respiratory stridor (Correct answer)
Correct answer: Respiratory stridor
Respiratory stridor in a child following a tonsillectomy is a critical finding that indicates airway obstruction. This could be due to swelling, hematoma formation, or laryngospasm, which are life-threatening complications. Immediate reporting is necessary to prevent respiratory distress and potential arrest, making it the most urgent concern among the options.
Question 2: The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
- Skips a meal
- Rests in recumbent position
- Eats a meal (Correct answer)
- Sits upright after eating
Correct answer: Eats a meal
Duodenal ulcers are typically characterized by pain that is relieved by eating food. Food acts as a buffer against stomach acid, which then moves into the duodenum, temporarily alleviating the discomfort. The pain usually recurs 2-3 hours after a meal or in the middle of the night when the stomach is empty, a pattern distinct from gastric ulcers.
Question 3: Which of the following meal selections is appropriate for the client with celiac disease?
- Toast, jam, and apple juice
- Peanut butter cookies and milk
- Rice Krispies bar and milk (Correct answer)
- Cheese pizza and Kool-Aid
Correct answer: Rice Krispies bar and milk
Celiac disease requires a strict gluten-free diet, meaning the avoidance of wheat, barley, and rye. Rice Krispies are made from rice, which is naturally gluten-free, making a Rice Krispies bar a safe and appropriate snack. The other options (toast, peanut butter cookies, cheese pizza) all contain wheat or other gluten-containing ingredients.
Question 4: A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
- The client complains of blurred vision.
- The client complains of increased thirst and increased urination. (Correct answer)
- The client complains of increased weight gain over the past year.
- The client complains of ringing in the ears.
Correct answer: The client complains of increased thirst and increased urination.
Increased thirst (polydipsia) and increased urination (polyuria) are classic signs of lithium toxicity, specifically nephrogenic diabetes insipidus, a common adverse effect. Lithium has a narrow therapeutic range, and these symptoms indicate a need for immediate assessment of lithium levels and kidney function. This is a critical indicator of a problem with the medication.
Question 5: A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
- Will need to be repeated when the child is 4 years of age
- Is given to determine whether the child is susceptible to pertussis
- Is one of a series of injections that protects against dpt and Hib (Correct answer)
- Is a one-time injection that protects against MMR and varicella
Correct answer: Is one of a series of injections that protects against dpt and Hib
Tetramune is a combination vaccine that provides protection against Diphtheria, Tetanus, Pertussis (DTaP), and Haemophilus influenzae type b (Hib). It is administered as part of a series of injections during infancy and early childhood. This multi-component vaccine helps protect against several serious childhood diseases with fewer injections.
Question 6: The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?
- Potato chips
- Diet cola
- Apple
- Milkshake (Correct answer)
Correct answer: Milkshake
Clients in a manic phase often have high energy levels, poor concentration, and may not sit long enough for a full meal, leading to inadequate nutritional intake. A milkshake is a high-calorie, nutrient-dense, and easily consumed liquid snack that provides essential energy and hydration. Its portability and minimal effort required for consumption make it ideal for someone with increased psychomotor activity.
Question 7: A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- “Currant jelly” stools (Correct answer)
- Projectile vomiting
- “Ribbon-like” stools
- Palpable mass over the flank
Correct answer: “Currant jelly” stools
''Currant jelly'' stools, which are a mixture of blood and mucus, are a classic symptom of intussusception. This finding indicates intestinal ischemia and potential necrosis as the bowel telescopes into itself, requiring urgent medical attention. Other options are associated with different pediatric gastrointestinal conditions.
Question 8: A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- Remove the unsightly markings with acetone or alcohol
- Cover the radiation site with loose gauze dressing
- Sprinkle baby powder over the irradiated area
- Refrain from using soap or lotion on the marked area (Correct answer)
Correct answer: Refrain from using soap or lotion on the marked area
The blue markings on the radiation site are crucial for accurate treatment delivery and must not be removed. Using soap, lotion, or scrubbing the area can irritate the sensitive skin and inadvertently erase these essential guides. Patients are typically instructed to protect the marked area and use only specific, approved skin care products.
Question 9: The nurse is caring for a client with acromegaly. Following a transsphenoidal hypophysectomy, the nurse should:
- Monitor the client’s blood sugar (Correct answer)
- Suction the mouth and pharynx every hour
- Place the client in low Trendelenburg position
- Encourage the client to cough
Correct answer: Monitor the client’s blood sugar
A transsphenoidal hypophysectomy involves the removal of the pituitary gland, which regulates various endocrine functions, including those affecting blood glucose. Post-operatively, there is a risk of developing diabetes insipidus (due to ADH deficiency) or other hormonal imbalances that can impact blood sugar regulation. Therefore, monitoring the client's blood sugar is essential to detect and manage potential complications.
NCLEX-PN Test #6
The nurse is caring for an 8-year-old following a routine tonsillectomy.
Which finding should be reported immediately?