NCLEX/RN/NCLEX RN TEST BANK ACTUAL
EXAM TESTS QUESTION AND ANSWERS
WITH RATIONALES VERIFIED 100%
CORRECT
Assess hip instability. Abducts thigh & applies gentle pressure forward over
greater trochanter. A "clicking" sensation indicates dislocated femoral head
moving into acetabulum. - ANSWER -Ortolani maneuver
confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain
reaction. - ANSWER -Detection of HIV in infants
Contains neomycin. History of anaphylactic reaction neomycin considered a
contraindication to IPV. - ANSWER -Inactivated polio vaccine (IPV)
Administered subcutaneously outer aspect of upper arm - ANSWER -(MMR)
vaccine
Transmitted airborne particles or direct contact with infectious droplets. Airborne
droplet precautions required, & should wear masks. Private room if hospitalized, &
door remains closed. Standard precautions used. Needs rest. consideration in
rubeola is eye care. Child usually has photophobia, suggest parent keep child out of
brightly lit areas. - ANSWER -Rubeola (measles)
Move safe area away from snake & rest to decrease venom circulation. Next
jewelry & constricting clothing removed before swelling occurs. Immobilize
extremity & maintain below heart level done next. Kept warm & calm. Stimulants
alcohol/caffeinated beverages not given: may speed absorption of venom -
ANSWER -snakebite first priority intervention
Infection dermis & underlying hypodermis: results in deep red erythema without
sharp borders & spreads widely throughout tissue spaces. Skin is erythematous,
,edematous, tender, & sometimes nodular. Antibiotic therapy; after blood cultures
obtained. Warm compresses to the affected area - ANSWER -Cellulitis
Lesions or patches appear as red, raised papules that may coalesce into large
plaques covered by silvery scales. Affected areas include scalp, elbows, knees,
shins, sacral area, & trunk. Incidence is lower in darker-skinned races & ethnic
groups. - ANSWER -Psoriasis
Pigmented malignant lesions originating melanin-producing cells of epidermis.
This skin cancer highly metastatic, & survival depends on early diagnosis &
treatment - ANSWER -Melanoma
The skin is intact in stage I. stage II, skin not intact. Partial-thickness skin loss
dermis. Shallow open ulcer with red-pink wound bed, without slough or intact,
open or ruptured, serum-filled blister. Full-thickness skin loss occurs stage III.
Exposed bone, tendon, muscle present stage IV - ANSWER -Pressure ulcers
Early signs Periorbital edema, edema face, tightness of a shirt or blouse collar. As
worsens, experiences edema hands & arms. Cyanosis & mental status changes are
late signs. - ANSWER -Superior vena cava syndrome
Classic symptoms polydipsia, polyuria, & polyphagia - ANSWER -
Hyperglycemia
Results from insufficient ADH production. Triad clinical symptoms including
polyuria, polydipsia, excessive thirst often occurs in client with diabetes insipidus.
Urine dilute, with specific gravity lower than 1.005, & urine osmolality low (50-
200 mOsm/L). High serum osmolality (>300 mOsm/kg of water). There is
(insufficient ADH production), which causes kidneys excrete large volumes of
urine. - ANSWER -Diabetes insipidus
Decreased blood glucose levels produce autonomic nervous system symptoms,
manifested as nervousness, irritability, & tremors. Usually feels hunger. Profuse
sweating & shakiness would be noted - ANSWER -Hypoglycemic reaction
, Caused by excessive amounts cortisol. Diet low carbohydrates & sodium but
ample protein/potassium encouraged. Promotes weight loss, reduction edema &
hypertension, control of hypokalemia, rebuilding of wasted tissue. Appearance
buffalo hump develop but most physical changes resolve with treatment. Rounded
moon-like face; prominent jowls; red cheeks; hirsutism upper lip, lower cheek, &
chin. (Moon facies & truncal obesity) - ANSWER -Cushing's syndrome
Catecholamine-producing tumor. Severe Hypertension can precipitate stroke or
sudden blindness. Monitor vital signs, particularly blood pressure. Normal range of
urinary catecholamines is14 mcg/100 mL of urine, higher levels in
pheochromocytoma. - ANSWER -Pheochromocytoma
Deficiency thyroid hormone. Puffy, edematous face, around eyes (periorbital
edema), along with coarse facial features, dry skin, & dry, coarse hair & eyebrows.
Feeling cold, hair loss, lethargy facial puffiness are signs. - ANSWER -
Hypothyroidism
Goiter (increase size thyroid gland) & exophthalmos (bulging eyeballs).
Nervousness, fatigue, weight loss, muscle cramps, heat intolerance. Tachycardia;
shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair & thin
skin; infrequent blinking; & staring appearance. - ANSWER -Hyperthyroidism
Acute, life-threatening condition occurs in uncontrollable hyperthyroidism.
Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal
pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial
fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition
progresses they become confused. Restless, anxious & experiences tachycardia. -
ANSWER -Thyroid storm
Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients
taking insulin. - ANSWER -Exenatide (Byetta)
Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion,
should be taken before meals approximately 30 minutes before meals & should be
withheld if client does not eat. Hypoglycemia is a side effect of repaglinide &
, client should always be prepared by carrying a simple sugar with her or him at all
times. - ANSWER -Repaglinide(Prandin)
Oral hypoglycemic given combination repaglinide, works decreasing hepatic
glucose production. Common side effect metformin is diarrhea. Used with caution;
kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol
consumption. - ANSWER -Metformin (Glucophage)
Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty
stomach enhance absorption. Dosing morning before breakfast. - ANSWER -
levothyroxine sodium (Synthroid)
Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert
hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced.
Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore
throat. - ANSWER -Propylthiouracil (PTU)
may decrease effect oral hypoglycemics, insulin, diuretics, & potassium
supplements. - ANSWER -Prednisone
Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing
by mouth) status decrease activity of pancreas. Pain management typically
administration opioids patient-controlled analgesia. Morphine or hydromorphone
(Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction
secretions & administer medications as necessary. - ANSWER -Acute pancreatitis
Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, &
alcohol - ANSWER -Gastroesophageal reflux disease (GERD
Inability absorb vitamin B12. This leads to development of pernicious anemia. -
ANSWER -Chronic gastritis
Nonbloody diarrhea usually not more than four to five stools daily. Over time,
diarrhea episodes increase in frequency, duration, & severity. - ANSWER -Crohn's
disease
EXAM TESTS QUESTION AND ANSWERS
WITH RATIONALES VERIFIED 100%
CORRECT
Assess hip instability. Abducts thigh & applies gentle pressure forward over
greater trochanter. A "clicking" sensation indicates dislocated femoral head
moving into acetabulum. - ANSWER -Ortolani maneuver
confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain
reaction. - ANSWER -Detection of HIV in infants
Contains neomycin. History of anaphylactic reaction neomycin considered a
contraindication to IPV. - ANSWER -Inactivated polio vaccine (IPV)
Administered subcutaneously outer aspect of upper arm - ANSWER -(MMR)
vaccine
Transmitted airborne particles or direct contact with infectious droplets. Airborne
droplet precautions required, & should wear masks. Private room if hospitalized, &
door remains closed. Standard precautions used. Needs rest. consideration in
rubeola is eye care. Child usually has photophobia, suggest parent keep child out of
brightly lit areas. - ANSWER -Rubeola (measles)
Move safe area away from snake & rest to decrease venom circulation. Next
jewelry & constricting clothing removed before swelling occurs. Immobilize
extremity & maintain below heart level done next. Kept warm & calm. Stimulants
alcohol/caffeinated beverages not given: may speed absorption of venom -
ANSWER -snakebite first priority intervention
Infection dermis & underlying hypodermis: results in deep red erythema without
sharp borders & spreads widely throughout tissue spaces. Skin is erythematous,
,edematous, tender, & sometimes nodular. Antibiotic therapy; after blood cultures
obtained. Warm compresses to the affected area - ANSWER -Cellulitis
Lesions or patches appear as red, raised papules that may coalesce into large
plaques covered by silvery scales. Affected areas include scalp, elbows, knees,
shins, sacral area, & trunk. Incidence is lower in darker-skinned races & ethnic
groups. - ANSWER -Psoriasis
Pigmented malignant lesions originating melanin-producing cells of epidermis.
This skin cancer highly metastatic, & survival depends on early diagnosis &
treatment - ANSWER -Melanoma
The skin is intact in stage I. stage II, skin not intact. Partial-thickness skin loss
dermis. Shallow open ulcer with red-pink wound bed, without slough or intact,
open or ruptured, serum-filled blister. Full-thickness skin loss occurs stage III.
Exposed bone, tendon, muscle present stage IV - ANSWER -Pressure ulcers
Early signs Periorbital edema, edema face, tightness of a shirt or blouse collar. As
worsens, experiences edema hands & arms. Cyanosis & mental status changes are
late signs. - ANSWER -Superior vena cava syndrome
Classic symptoms polydipsia, polyuria, & polyphagia - ANSWER -
Hyperglycemia
Results from insufficient ADH production. Triad clinical symptoms including
polyuria, polydipsia, excessive thirst often occurs in client with diabetes insipidus.
Urine dilute, with specific gravity lower than 1.005, & urine osmolality low (50-
200 mOsm/L). High serum osmolality (>300 mOsm/kg of water). There is
(insufficient ADH production), which causes kidneys excrete large volumes of
urine. - ANSWER -Diabetes insipidus
Decreased blood glucose levels produce autonomic nervous system symptoms,
manifested as nervousness, irritability, & tremors. Usually feels hunger. Profuse
sweating & shakiness would be noted - ANSWER -Hypoglycemic reaction
, Caused by excessive amounts cortisol. Diet low carbohydrates & sodium but
ample protein/potassium encouraged. Promotes weight loss, reduction edema &
hypertension, control of hypokalemia, rebuilding of wasted tissue. Appearance
buffalo hump develop but most physical changes resolve with treatment. Rounded
moon-like face; prominent jowls; red cheeks; hirsutism upper lip, lower cheek, &
chin. (Moon facies & truncal obesity) - ANSWER -Cushing's syndrome
Catecholamine-producing tumor. Severe Hypertension can precipitate stroke or
sudden blindness. Monitor vital signs, particularly blood pressure. Normal range of
urinary catecholamines is14 mcg/100 mL of urine, higher levels in
pheochromocytoma. - ANSWER -Pheochromocytoma
Deficiency thyroid hormone. Puffy, edematous face, around eyes (periorbital
edema), along with coarse facial features, dry skin, & dry, coarse hair & eyebrows.
Feeling cold, hair loss, lethargy facial puffiness are signs. - ANSWER -
Hypothyroidism
Goiter (increase size thyroid gland) & exophthalmos (bulging eyeballs).
Nervousness, fatigue, weight loss, muscle cramps, heat intolerance. Tachycardia;
shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair & thin
skin; infrequent blinking; & staring appearance. - ANSWER -Hyperthyroidism
Acute, life-threatening condition occurs in uncontrollable hyperthyroidism.
Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal
pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial
fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition
progresses they become confused. Restless, anxious & experiences tachycardia. -
ANSWER -Thyroid storm
Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients
taking insulin. - ANSWER -Exenatide (Byetta)
Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion,
should be taken before meals approximately 30 minutes before meals & should be
withheld if client does not eat. Hypoglycemia is a side effect of repaglinide &
, client should always be prepared by carrying a simple sugar with her or him at all
times. - ANSWER -Repaglinide(Prandin)
Oral hypoglycemic given combination repaglinide, works decreasing hepatic
glucose production. Common side effect metformin is diarrhea. Used with caution;
kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol
consumption. - ANSWER -Metformin (Glucophage)
Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty
stomach enhance absorption. Dosing morning before breakfast. - ANSWER -
levothyroxine sodium (Synthroid)
Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert
hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced.
Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore
throat. - ANSWER -Propylthiouracil (PTU)
may decrease effect oral hypoglycemics, insulin, diuretics, & potassium
supplements. - ANSWER -Prednisone
Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing
by mouth) status decrease activity of pancreas. Pain management typically
administration opioids patient-controlled analgesia. Morphine or hydromorphone
(Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction
secretions & administer medications as necessary. - ANSWER -Acute pancreatitis
Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, &
alcohol - ANSWER -Gastroesophageal reflux disease (GERD
Inability absorb vitamin B12. This leads to development of pernicious anemia. -
ANSWER -Chronic gastritis
Nonbloody diarrhea usually not more than four to five stools daily. Over time,
diarrhea episodes increase in frequency, duration, & severity. - ANSWER -Crohn's
disease
