NCLEX RN Priority and Delegation
Questions | NCLEX RN Practice
Questions with Rationales
1. 1. Question
A client with bacterial pneumonia is admitted to the pediatric unit. What would
the nurse expect the admitting assessment to reveal?
A. High fever
B. Nonproductive cough
C. Rhinitis
D. Vomiting and diarrhea
Correct Answer: A. High fever
If the child has bacterial pneumonia, a high fever is usually present. Increased
temperature (usually more than 38 C or 100.4 F) or fever with tachycardia and/or
chills and sweats is a major clinical finding. Physical findings also vary from
patient to patient and mainly depend on the severity of lung consolidation, the
type of organism, the extent of the infection, host factors, and existence or
nonexistence of pleural effusion.
Option B: Bacterial pneumonia usually presents with a productive cough, not
a nonproductive cough. The presence of a productive cough is the most
common and significant presenting symptom. The lower respiratory tract is
not sterile, and it always is exposed to environmental pathogens. Invasion and
propagation of the above-mentioned bacteria into lung parenchyma at
alveolar level causes bacterial pneumonia, and the body’s inflammatory
response against it causes the clinical syndrome of pneumonia.
Option C: Rhinitis is often seen with viral pneumonia. Features in the history of
bacterial pneumonia may vary from indolent to fulminant. Clinical
manifestation includes both constitutional findings and findings due to
damage to the lung and related tissue.
Page 1 of 29
, Option D: Vomiting and diarrhea are usually not seen with pneumonia.
Atypical pneumonia presents with pulmonary and extrapulmonary
manifestations, such as Legionella pneumonia, often presents with altered
mentation and gastrointestinal symptoms.
2. 2. Question
The nurse is caring for a client admitted with epiglottitis. Because of the
possibility of complete obstruction of the airway, which of the following should
the nurse have available?
A. Intravenous access supplies
B. A tracheostomy set
C. Intravenous fluid administration pump
D. Supplemental oxygen
Correct Answer: B. A tracheostomy set
For a child with epiglottitis and the possibility of complete obstruction of the
airway, emergency tracheostomy equipment should always be kept at the
bedside. Prepare for intubation or tracheostomy; Anticipate the need of an
artificial airway. An artificial airway is required to promote oxygenation and
ventilation and prevent aspiration.
Option A: Administer IV antibiotics as ordered. After obtaining blood and
epiglottic cultures, second-or-third generation cephalosporins and beta-
lactamase-resistant antibiotics should be started as soon as possible.
Option C: Discourage examining throat with a tongue blade or taking throat
culture unless immediate emergency equipment and personnel at hand.
Position the child in a sitting up and leaning forward position with mouth open
and tongue out (“tripod” position). Allows maximum entry of air into the lungs
for improved oxygenation.
Option D: Oxygen will not treat an obstruction. Endotracheal intubation must
be readily available; assist with tracheostomy if needed or prepare for the
procedure in surgery. Establishes airway if obstruction present and respiratory
failure and asphyxia are imminent.
3. 3. Question
A 25-year-old client with Grave’s disease is admitted to the unit. What would the
nurse expect the admitting assessment to reveal?
Page 2 of 29
, A. Bradycardia
B. Decreased appetite
C. Exophthalmos
D. Weight gain
Correct Answer: C. Exophthalmos
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Graves’
orbitopathy (ophthalmopathy) is caused by inflammation, cellular proliferation
and increased growth of extraocular muscles and retro-orbital connective and
adipose tissues due to the actions of thyroid stimulating antibodies and cytokines
released by cytotoxic T lymphocytes (killer cells). These cytokines and thyroid
stimulating antibodies activate periorbital fibroblasts and preadipocytes, causing
synthesis of excess hydrophilic glycosaminoglycans (GAG) and retro-orbital fat
growth.
Option A: Physical signs of hyperthyroidism include tachycardia, systolic
hypertension with increased pulse pressure, signs of heart failure (like edema,
rales, jugular venous distension, tachypnea), atrial fibrillation, fine tremors,
hyperkinesia, hyperreflexia, warm and moist skin, palmar erythema and
onycholysis, hair loss, diffuse palpable goiter with thyroid bruit and altered
mental status.
Option B: Hyperthyroidism usually increases the appetite. If the client is taking
in a lot more calories, they can gain weight even if their body is burning more
energy. Make sure to eat healthy foods, get regular exercise, and work with a
doctor on a nutrition plan. These steps can all help combat weight gain from
an increased appetite.
Option D: In younger patients, common presentations include heat
intolerance, sweating, fatigue, weight loss, palpitation, hyper defecation, and
tremors. Other features include insomnia, anxiety, nervousness, hyperkinesia,
dyspnea, muscle weakness, pruritus, polyuria, oligomenorrhea or amenorrhea
in the female, loss of libido, and neck fullness.
4. 4. Question
Category: Health Promotion and Maintenance
The nurse is providing dietary instructions to the mother of an 8-year-old child
diagnosed with celiac disease. Which of the following foods, if selected by the
mother, would indicate her understanding of the dietary instructions?
Page 3 of 29
Questions | NCLEX RN Practice
Questions with Rationales
1. 1. Question
A client with bacterial pneumonia is admitted to the pediatric unit. What would
the nurse expect the admitting assessment to reveal?
A. High fever
B. Nonproductive cough
C. Rhinitis
D. Vomiting and diarrhea
Correct Answer: A. High fever
If the child has bacterial pneumonia, a high fever is usually present. Increased
temperature (usually more than 38 C or 100.4 F) or fever with tachycardia and/or
chills and sweats is a major clinical finding. Physical findings also vary from
patient to patient and mainly depend on the severity of lung consolidation, the
type of organism, the extent of the infection, host factors, and existence or
nonexistence of pleural effusion.
Option B: Bacterial pneumonia usually presents with a productive cough, not
a nonproductive cough. The presence of a productive cough is the most
common and significant presenting symptom. The lower respiratory tract is
not sterile, and it always is exposed to environmental pathogens. Invasion and
propagation of the above-mentioned bacteria into lung parenchyma at
alveolar level causes bacterial pneumonia, and the body’s inflammatory
response against it causes the clinical syndrome of pneumonia.
Option C: Rhinitis is often seen with viral pneumonia. Features in the history of
bacterial pneumonia may vary from indolent to fulminant. Clinical
manifestation includes both constitutional findings and findings due to
damage to the lung and related tissue.
Page 1 of 29
, Option D: Vomiting and diarrhea are usually not seen with pneumonia.
Atypical pneumonia presents with pulmonary and extrapulmonary
manifestations, such as Legionella pneumonia, often presents with altered
mentation and gastrointestinal symptoms.
2. 2. Question
The nurse is caring for a client admitted with epiglottitis. Because of the
possibility of complete obstruction of the airway, which of the following should
the nurse have available?
A. Intravenous access supplies
B. A tracheostomy set
C. Intravenous fluid administration pump
D. Supplemental oxygen
Correct Answer: B. A tracheostomy set
For a child with epiglottitis and the possibility of complete obstruction of the
airway, emergency tracheostomy equipment should always be kept at the
bedside. Prepare for intubation or tracheostomy; Anticipate the need of an
artificial airway. An artificial airway is required to promote oxygenation and
ventilation and prevent aspiration.
Option A: Administer IV antibiotics as ordered. After obtaining blood and
epiglottic cultures, second-or-third generation cephalosporins and beta-
lactamase-resistant antibiotics should be started as soon as possible.
Option C: Discourage examining throat with a tongue blade or taking throat
culture unless immediate emergency equipment and personnel at hand.
Position the child in a sitting up and leaning forward position with mouth open
and tongue out (“tripod” position). Allows maximum entry of air into the lungs
for improved oxygenation.
Option D: Oxygen will not treat an obstruction. Endotracheal intubation must
be readily available; assist with tracheostomy if needed or prepare for the
procedure in surgery. Establishes airway if obstruction present and respiratory
failure and asphyxia are imminent.
3. 3. Question
A 25-year-old client with Grave’s disease is admitted to the unit. What would the
nurse expect the admitting assessment to reveal?
Page 2 of 29
, A. Bradycardia
B. Decreased appetite
C. Exophthalmos
D. Weight gain
Correct Answer: C. Exophthalmos
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. Graves’
orbitopathy (ophthalmopathy) is caused by inflammation, cellular proliferation
and increased growth of extraocular muscles and retro-orbital connective and
adipose tissues due to the actions of thyroid stimulating antibodies and cytokines
released by cytotoxic T lymphocytes (killer cells). These cytokines and thyroid
stimulating antibodies activate periorbital fibroblasts and preadipocytes, causing
synthesis of excess hydrophilic glycosaminoglycans (GAG) and retro-orbital fat
growth.
Option A: Physical signs of hyperthyroidism include tachycardia, systolic
hypertension with increased pulse pressure, signs of heart failure (like edema,
rales, jugular venous distension, tachypnea), atrial fibrillation, fine tremors,
hyperkinesia, hyperreflexia, warm and moist skin, palmar erythema and
onycholysis, hair loss, diffuse palpable goiter with thyroid bruit and altered
mental status.
Option B: Hyperthyroidism usually increases the appetite. If the client is taking
in a lot more calories, they can gain weight even if their body is burning more
energy. Make sure to eat healthy foods, get regular exercise, and work with a
doctor on a nutrition plan. These steps can all help combat weight gain from
an increased appetite.
Option D: In younger patients, common presentations include heat
intolerance, sweating, fatigue, weight loss, palpitation, hyper defecation, and
tremors. Other features include insomnia, anxiety, nervousness, hyperkinesia,
dyspnea, muscle weakness, pruritus, polyuria, oligomenorrhea or amenorrhea
in the female, loss of libido, and neck fullness.
4. 4. Question
Category: Health Promotion and Maintenance
The nurse is providing dietary instructions to the mother of an 8-year-old child
diagnosed with celiac disease. Which of the following foods, if selected by the
mother, would indicate her understanding of the dietary instructions?
Page 3 of 29
