NGN/NCLEX Prep Questions/Rationales With Complete
Solutions
A 4-year-old child admitted 1 day ago to the pediatric unit is
suspected of having periorbital cellulitis of the right eye with
associated impetigo. Which of the current findings would be
essential to follow up on?Click to highlight the current
finding(s) that would be essential to follow up on. Highlight
only finding(s) that require follow-up. To deselect a finding,
click the finding again. Correct Answer ParameterCurrent8
hours ago24 hours agoBlood pressure92/64 mm Hg98/70 mm
Hg99/70 mm HgPulse✓126 beats per minute120 beats per
minute116 beats per minuteRespirations18 breaths per minute20
breaths per minute18 breaths per minuteOral temperature✓38.4°
C (101.2° F)37.8° C (100° F)37.6° C (99.9° F)
Laboratory testCurrent24 hours agoWhite blood
cell✓18,400/mm3 (18.4 x 103/uL)15,200/mm3 (15.2 x
103/uL)Hemoglobin15.2 g/dL (152 mmol/L)15.0 g/dL (150
mmol/L)Hematocrit38% (0.38)39% (0.39)
Cranial nerve testCurrent24 hours agoCranial nerve II20/20 left
eye20/20 both eyes✓20/40 right eyeCranial nerve IIIExtraocular
movements intact,Extraocular movements intact, no
nystagmus✓pain associated with movements in right eye
2 4 5 9 11
Rationale:Periorbital cellulitis is an acute infection characterized
by pain, erythema, and edema of the anterior eyelid and tissue
surrounding the eye. The risk with periorbital cellulitis is that it
can progress to orbital cellulitis and can threaten vision.
Antibiotics should be prescribed, and intravenous antibiotics
,may be required depending on the clinical findings. If
bacteremia is suspected, a complete blood count may be done,
and vital signs will be monitored closely. Physical assessment
should focus on visual acuity and extraocular movements. An
increase in pulse rate, increase in temperature, increased white
blood cell count, decreased visual acuity, and increased pain on
extraocular movements in the affected eye are all findings that
constitute a worsening of the condition and should be followed
up on promptly to preserve vision.
A child suddenly vomits. The nurse takes the following actions
to ensure safety. Select the Rationale for each Nursing Action.
Correct Answer Nursing ActionsRationalPosition the child
upright or on the side.Your Answer:1. This allows the child to
maintain a patent airway.Correct Answer:1. This allows the
child to maintain a patent airway.Perform oral suctioning.Your
Answer:1. This allows the child to maintain a patent
airway.Correct Answer:1. This allows the child to maintain a
patent airway.Assess the character and amount of vomitus.Your
Answer:3. This will provide information about possible causes
of the vomiting episode.Correct Answer:3. This will provide
information about possible causes of the vomiting
episode.Assess the force of the vomiting.Your Answer:3. This
will provide information about possible causes of the vomiting
episode.Correct Answer:3. This will provide information about
possible causes of the vomiting episode.Monitor intake and
output and vital signs.Your Answer:2. This will be helpful in
monitoring for complications of the vomiting episode.Correct
Answer:2. This will be helpful in monitoring for complications
of the vomiting episode.
,Rationale:If a child suddenly vomits, the nurse must maintain a
patent airway. The child should be positioned upright or on the
side to prevent aspiration. Suctioning equipment should be
obtained, kept at the bedside, and used if needed to assist in
maintaining a patent airway. The nurse should check the
character and amount of the vomitus as this will provide
information about possible causes of the vomiting episode. The
force of the vomiting should be assessed because projectile
vomiting may indicate pyloric stenosis or increased intracranial
pressure, which are possible causes. The nurse should also
monitor intake and output and vital signs to monitor for the
complication of dehydration.
A client has been diagnosed with chronic kidney disease. The
nurse anticipates specific dietary prescriptions due to the risks
associated with chronic kidney disease. Fill in the correct
missing information by choosing from the lists of options in the
drop-down menus. Correct Answer The nurse should note the
client is
Your Answer: On a fluid restriction
Correct Answer: On a fluid restriction
because
Your Answer: Of the risk of hypervolemia
Correct Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: Chew gum
Correct Answer: Chew gum
because
Your Answer: it doesn't contribute to hypervolemia
Correct Answer: it doesn't contribute to hypervolemia
, Rationale:The client with chronic kidney disease may be placed
on fluid restriction because of decreased renal function and
glomerular filtration rate, resulting in fluid volume excess. To
allow the kidneys to rest, decreased fluid consumption may be
indicated. When a client is placed on this restriction, increased
thirst may be a problem. The nurse should instruct the client in
measures to relieve thirst in order to promote adherence to the
fluid restriction. These measures include chewing gum or
sucking hard candy, freezing fluids so they take longer to
consume, adding lemon juice to allowed water to make it more
refreshing, and gargling with refrigerated mouthwash.
A client who is bedbound and incontinent has been diagnosed
with heart failure exacerbation. The nurse anticipates specific
prescriptions due to the risks associated with heart failure. Fill in
the correct missing information by choosing from the lists of
options in the drop-down menus. Correct Answer The nurse
should note the client is
Your Answer: On a fluid restrictionCorrect Answer: On a fluid
restriction
because
Your Answer: of the risk of hypervolemiaCorrect Answer: of
the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: use lemon swabsCorrect Answer: use lemon
swabs
because
Your Answer: it doesn't contribute to hypervolemiaCorrect
Answer: it doesn't contribute to hypervolemia
The nurse notes that in order to effectively monitor diuretic
therapy, a prescription for
Solutions
A 4-year-old child admitted 1 day ago to the pediatric unit is
suspected of having periorbital cellulitis of the right eye with
associated impetigo. Which of the current findings would be
essential to follow up on?Click to highlight the current
finding(s) that would be essential to follow up on. Highlight
only finding(s) that require follow-up. To deselect a finding,
click the finding again. Correct Answer ParameterCurrent8
hours ago24 hours agoBlood pressure92/64 mm Hg98/70 mm
Hg99/70 mm HgPulse✓126 beats per minute120 beats per
minute116 beats per minuteRespirations18 breaths per minute20
breaths per minute18 breaths per minuteOral temperature✓38.4°
C (101.2° F)37.8° C (100° F)37.6° C (99.9° F)
Laboratory testCurrent24 hours agoWhite blood
cell✓18,400/mm3 (18.4 x 103/uL)15,200/mm3 (15.2 x
103/uL)Hemoglobin15.2 g/dL (152 mmol/L)15.0 g/dL (150
mmol/L)Hematocrit38% (0.38)39% (0.39)
Cranial nerve testCurrent24 hours agoCranial nerve II20/20 left
eye20/20 both eyes✓20/40 right eyeCranial nerve IIIExtraocular
movements intact,Extraocular movements intact, no
nystagmus✓pain associated with movements in right eye
2 4 5 9 11
Rationale:Periorbital cellulitis is an acute infection characterized
by pain, erythema, and edema of the anterior eyelid and tissue
surrounding the eye. The risk with periorbital cellulitis is that it
can progress to orbital cellulitis and can threaten vision.
Antibiotics should be prescribed, and intravenous antibiotics
,may be required depending on the clinical findings. If
bacteremia is suspected, a complete blood count may be done,
and vital signs will be monitored closely. Physical assessment
should focus on visual acuity and extraocular movements. An
increase in pulse rate, increase in temperature, increased white
blood cell count, decreased visual acuity, and increased pain on
extraocular movements in the affected eye are all findings that
constitute a worsening of the condition and should be followed
up on promptly to preserve vision.
A child suddenly vomits. The nurse takes the following actions
to ensure safety. Select the Rationale for each Nursing Action.
Correct Answer Nursing ActionsRationalPosition the child
upright or on the side.Your Answer:1. This allows the child to
maintain a patent airway.Correct Answer:1. This allows the
child to maintain a patent airway.Perform oral suctioning.Your
Answer:1. This allows the child to maintain a patent
airway.Correct Answer:1. This allows the child to maintain a
patent airway.Assess the character and amount of vomitus.Your
Answer:3. This will provide information about possible causes
of the vomiting episode.Correct Answer:3. This will provide
information about possible causes of the vomiting
episode.Assess the force of the vomiting.Your Answer:3. This
will provide information about possible causes of the vomiting
episode.Correct Answer:3. This will provide information about
possible causes of the vomiting episode.Monitor intake and
output and vital signs.Your Answer:2. This will be helpful in
monitoring for complications of the vomiting episode.Correct
Answer:2. This will be helpful in monitoring for complications
of the vomiting episode.
,Rationale:If a child suddenly vomits, the nurse must maintain a
patent airway. The child should be positioned upright or on the
side to prevent aspiration. Suctioning equipment should be
obtained, kept at the bedside, and used if needed to assist in
maintaining a patent airway. The nurse should check the
character and amount of the vomitus as this will provide
information about possible causes of the vomiting episode. The
force of the vomiting should be assessed because projectile
vomiting may indicate pyloric stenosis or increased intracranial
pressure, which are possible causes. The nurse should also
monitor intake and output and vital signs to monitor for the
complication of dehydration.
A client has been diagnosed with chronic kidney disease. The
nurse anticipates specific dietary prescriptions due to the risks
associated with chronic kidney disease. Fill in the correct
missing information by choosing from the lists of options in the
drop-down menus. Correct Answer The nurse should note the
client is
Your Answer: On a fluid restriction
Correct Answer: On a fluid restriction
because
Your Answer: Of the risk of hypervolemia
Correct Answer: of the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: Chew gum
Correct Answer: Chew gum
because
Your Answer: it doesn't contribute to hypervolemia
Correct Answer: it doesn't contribute to hypervolemia
, Rationale:The client with chronic kidney disease may be placed
on fluid restriction because of decreased renal function and
glomerular filtration rate, resulting in fluid volume excess. To
allow the kidneys to rest, decreased fluid consumption may be
indicated. When a client is placed on this restriction, increased
thirst may be a problem. The nurse should instruct the client in
measures to relieve thirst in order to promote adherence to the
fluid restriction. These measures include chewing gum or
sucking hard candy, freezing fluids so they take longer to
consume, adding lemon juice to allowed water to make it more
refreshing, and gargling with refrigerated mouthwash.
A client who is bedbound and incontinent has been diagnosed
with heart failure exacerbation. The nurse anticipates specific
prescriptions due to the risks associated with heart failure. Fill in
the correct missing information by choosing from the lists of
options in the drop-down menus. Correct Answer The nurse
should note the client is
Your Answer: On a fluid restrictionCorrect Answer: On a fluid
restriction
because
Your Answer: of the risk of hypervolemiaCorrect Answer: of
the risk of hypervolemia
To relieve the thirst, the nurse should instruct the client to
Your Answer: use lemon swabsCorrect Answer: use lemon
swabs
because
Your Answer: it doesn't contribute to hypervolemiaCorrect
Answer: it doesn't contribute to hypervolemia
The nurse notes that in order to effectively monitor diuretic
therapy, a prescription for
