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NCLEX National Council Licensure Examination(NCLEX-RN) Sample Questions (Q22-Q27):

NEW QUESTION # 22
An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:

  • A. Has sustained an internal injury in addition to the head injury
  • B. Has a sudden and severe increase in intracranial pressure
  • C. Is beginning to experience a dangerously high level of anxiety
  • D. Is having intracranial bleeding

Answer: A

Explanation:
(A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.


NEW QUESTION # 23
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:

  • A. Reduce mother's sense of guilt
  • B. Teach parents appropriate safety precautions
  • C. Determine child's activity pattern
  • D. Instruct parents in use of ipecac

Answer: B

Explanation:
Section: Questions Set G
Explanation
Explanation:
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.


NEW QUESTION # 24
When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?

  • A. Elevated serum protein
  • B. Elevated serum sodium
  • C. Elevated hematocrit
  • D. Elevated serum calcium

Answer: C

Explanation:
Explanation
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid.
Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.


NEW QUESTION # 25
Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as:

  • A. Nearsightedness
  • B. Cataracts
  • C. Lazy eye
  • D. Farsightedness

Answer: A

Explanation:
Explanation
(A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens.
(B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects.
(C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D) Lazyeye refers to strabismus or misalignment of the eyes.


NEW QUESTION # 26
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms.
Which of the following nursing interventions is the most accurate measure to include in his care?

  • A. Observe for edema.
  • B. Weigh the child twice daily on the same scale.
  • C. Check urine specific gravity of each voiding.
  • D. Monitor intake and output.

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. (B) Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. (C) Urine specific gravity does not necessarily indicatefluid volume excess. (D) Edema may not be apparent, yet the client may have fluid volume excess.


NEW QUESTION # 27
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