NCLEX-PN Test #18 2 — Questions and Answers
Question 1: A client with cirrhosis develops asterixis (liver flap). What does this finding indicate?
- Portal hypertension with esophageal varices
- Hepatic encephalopathy from ammonia accumulation (Correct answer)
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
Correct answer: Hepatic encephalopathy from ammonia accumulation
Asterixis (flapping tremor of the extended hands) is a classic neurological sign of hepatic encephalopathy caused by elevated blood ammonia (from impaired liver detoxification). It represents toxic brain dysfunction. Treatment includes lactulose (to excrete ammonia in stool) and rifaximin (to reduce ammonia-producing gut bacteria). Protein restriction may be considered.
Question 2: A client with end-stage renal disease (ESRD) on hemodialysis reports swelling of the AV fistula arm, no bruit, and no thrill. What does the nurse suspect?
- Normal post-dialysis finding
- AV fistula thrombosis (clotting) (Correct answer)
- Infection at the fistula site
- Aneurysm formation
Correct answer: AV fistula thrombosis (clotting)
The absence of a bruit (heard with stethoscope) and thrill (felt on palpation) in an AV fistula indicates thrombosis (clotting), which is a dialysis access emergency. The provider must be notified immediately for possible thrombectomy or interventional radiology consultation. Without a functioning fistula, hemodialysis cannot be performed.
Question 3: A client with hyperthyroidism is prescribed propylthiouracil (PTU). Which laboratory result indicates treatment effectiveness?
- Increasing TSH levels and normalizing free T4 (Correct answer)
- Decreasing TSH levels with rising T3 and T4
- Elevated antithyroid antibody levels
- Increasing serum calcium levels
Correct answer: Increasing TSH levels and normalizing free T4
PTU inhibits thyroid hormone synthesis. Effective treatment results in decreasing T3/T4 levels and rising TSH (as the pituitary responds to lower thyroid hormone by increasing TSH). Normalizing TSH and free T4 into the therapeutic range indicates successful treatment of hyperthyroidism.
Question 4: A client is admitted with acute pyelonephritis. Which clinical finding best differentiates pyelonephritis from a lower UTI (cystitis)?
- Dysuria and frequency
- Costovertebral angle (CVA) tenderness, fever, and chills (Correct answer)
- Foul-smelling urine with sediment
- Urinary urgency with low-grade fever
Correct answer: Costovertebral angle (CVA) tenderness, fever, and chills
Acute pyelonephritis involves upper urinary tract (kidney) infection. CVA tenderness (flank pain at the costovertebral angle, elicited by percussion), high fever (≥38.5°C), and systemic symptoms (chills, nausea, vomiting) distinguish it from lower UTI. Lower UTI (cystitis) causes dysuria, frequency, and urgency without systemic involvement or CVA tenderness.
Question 5: A client with hypovolemia requires a fluid challenge. The PN prepares to infuse 250 mL of 0.9% NS over 15 minutes. During infusion, the client develops increasing shortness of breath and crackles at the lung bases. What is the priority action?
- Increase the infusion rate to complete the challenge as ordered
- Stop the infusion and notify the provider — signs of fluid overload are present (Correct answer)
- Reposition the client and continue the infusion at a slower rate
- Administer a bronchodilator for the new respiratory symptoms
Correct answer: Stop the infusion and notify the provider — signs of fluid overload are present
New onset shortness of breath with bibasilar crackles during IV fluid administration indicates pulmonary edema from fluid overload. The priority is to immediately stop the infusion and notify the provider. Diuretic therapy (furosemide) and supplemental oxygen will likely be ordered. Continuing fluid administration will worsen the condition.
Question 6: The nurse is caring for a client with a urinary catheter. While emptying the drainage bag, the nurse notes the urine has a strong odor and is dark amber with sediment. What is the appropriate action?
- Document the finding and recheck at the next shift
- Obtain a urine specimen for culture and sensitivity and notify the provider (Correct answer)
- Increase IV fluid rate to dilute the urine
- Change the Foley catheter immediately without notifying the provider
Correct answer: Obtain a urine specimen for culture and sensitivity and notify the provider
Strong odor, dark amber color, and sediment are signs of possible urinary tract infection or dehydration in a catheterized client. A catheter-associated UTI (CAUTI) is a common hospital-acquired infection. The nurse should collect a urine specimen (from the sampling port — not the drainage bag) for culture before antibiotic therapy, and notify the provider.
NCLEX-PN Test #18 2
A client with cirrhosis develops asterixis (liver flap).
What does this finding indicate?