SAUNDERS NCLEX RN PRETEST REVIEW EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS

SAUNDERS NCLEX RN PRETEST REVIEW EXAM QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS Terms in this set (27) Content: acetylsalicylic acid (aspirin) poisoning A 5 year old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? 1. Administer ipecac by mouth and monitor emesis. 2. Institute a gastric lavage and administer activated charcoal. 3. Administer a chelating agent such as edetate calcium disodium. 4. Institute a gastric lavage and administer the antidote acetylcysteine. Answer: 2. Institute a gastric lavage and administer activated charcoal Rationale: A gastric lavage must be performed after ingestion of acetylsalicylic acid, and activated charcoal is administered to prevent further absorption of the substance. N-acetylcysteine is the antidote for acetaminophen. Administering ipecac or edetate calcium disodium is not a treatment measure for acetylsalicylic acid poisoning. Edetate calcium disodium may be prescribed for the treatment of lead poisoning. Ipecac causes vomiting, and this substance is used only in specific poisoning conditions; in this situation, vomiting can cause irritation of the esophagus. The nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply. 1. Proteinuria 2. Hematuria 3. Positive ketones 4. A low specific gravity 5. A dark and smoky appearance of the urine answer: 1, 2, 5 Rationale: In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. The specific gravity is elevated, and the urine may appear dark and smoky. Positive ketones are not associated with this condition but may indicate a secondary problem. A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? 1. Grandiose delusions of being a czar of Russia 2. Constant physical activity and poor oral intake 3. Constant, incessant talking, with sexual innuendoes 4. Outlandish behaviors and wearing odd, eccentric clothing answer: 2 Rationale: Mania is a period when the mood is predominantly elevated, expansive, or irritable. The client's mood may be characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Each of the options is reflective of possible symptoms. The need for adequate food and rest is the priority. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime. answer: 2 Rationale: A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water. The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. Vomiting 2. Bulging anterior fontanel 3. Increasing head circumference 4. Complaints of a frontal headache answer: 1 Rationale: The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanel closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children. The client with a traumatic brain injury (TBI) has begun excreting copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the health care provider will prescribe which medication? 1. Mannitol 2. Desmopressin 3. Ethacrynic acid 4. Dexamethasone answer: 2 Rationale: A complication of TBI is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone is usually given to control cerebral edema secondary to brain tumors. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.