NCLEX-PN 연습 시험 6
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
Respiratory stridor is a symptom of partial airway obstruction. Answers A, B, and C are expected with a tonsillectomy; therefore, they are incorrect.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Answer A is incorrect because it makes the pain worse. Answer B refers to dumping syndrome; therefore, it is incorrect. Answer D refers to gastroesophageal reflux; therefore, it is incorrect.
Which of the following meal selections is appropriate for the client with celiac disease?
Foods containing rice or millet are permitted on the diet of the client with celiac disease. Answers A, B, and D are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.
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?
Increased thirst and increased urination are signs of lithium toxicity. Answers B and D do not relate to the medication; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect.
A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenzae b. Answer A is incorrect because a second injection is given before 4 years of age. Answer B is not a true statement; therefore, it is incorrect. Answer D is incorrect because it is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.
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?
The milkshake will provide needed calories and nutrients for the client with mania. Answers A and B are incorrect because they are high in sodium, which causes the client to excrete the lithium. Answer C has some nutrient value, but not as much as the milkshake.
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
The child with intussusception has stools that contain blood and mucus, which are described as “currant jelly” stools. Answer B is a symptom of pyloric stenosis; therefore, it is incorrect. Answer C is a symptom of Hirschsprung’s; therefore, it is incorrect. Answer D is a symptom of Wilms tumor; therefore, it is incorrect.
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:
The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Answer A is incorrect because it would remove the marking. Answers B and C are not necessary for the client receiving radiation; therefore, they are incorrect.
The nurse is caring for a client with acromegaly. Following a transsphenoidal hypophysectomy, the nurse should:
Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Answer B is incorrect because it traumatizes the oral mucosa. Answer C is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Answer D is incorrect because it increases pressure on the operative site that can lead to a leak of cerebrospinal fluid.