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NCLEX-RN Exam Questions - Part 8
1. A laboratory technique specific for diagnosing Lyme disease is:
A) Polymerase chain reaction
B) Heterophil antibody test
C) Decreased serum calcium level
D) Increased serum potassium level
2. The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
A) Complete bed rest for 6 - 8 weeks
B) Tetracycline treatment
C) IV amphotericin B
D) High-protein diet with limited fluids
3. A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
A) Blood pressure
B) Serum potassium level
C) Urine output
D) Pulse rate
4. Proper positioning for the child who is in Bryant - s traction is:
A) Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
B) Both legs extended, and the hips are not flexed
C) The affected leg extended with slight hip flexion
D) Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
5. A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
A) Bleeding, bruising, and hemorrhage
B) Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
C) Pain, pallor, pulselessness, paresthesia, and paralysis
D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
A) Polymerase chain reaction
B) Heterophil antibody test
C) Decreased serum calcium level
D) Increased serum potassium level
2. The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
A) Complete bed rest for 6 - 8 weeks
B) Tetracycline treatment
C) IV amphotericin B
D) High-protein diet with limited fluids
3. A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
A) Blood pressure
B) Serum potassium level
C) Urine output
D) Pulse rate
4. Proper positioning for the child who is in Bryant - s traction is:
A) Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
B) Both legs extended, and the hips are not flexed
C) The affected leg extended with slight hip flexion
D) Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
5. A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
A) Bleeding, bruising, and hemorrhage
B) Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
C) Pain, pallor, pulselessness, paresthesia, and paralysis
D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
1. Right Answer: A
Explanation: (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
2. Right Answer: B
Explanation: (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9.(C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.
3. Right Answer: C
Explanation: (A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation.(C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
4. Right Answer: A
Explanation: (A) The childs weight supplies the countertraction for Bryants traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle.Both legs are suspended by skin traction. (B) The child in Bucks extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in '90 90' traction maintains both hips and knees at a90-degree flexion angle and the back is flat on the bed.
5. Right Answer: C
Explanation: (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P s': pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
Explanation: (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
2. Right Answer: B
Explanation: (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9.(C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.
3. Right Answer: C
Explanation: (A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation.(C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
4. Right Answer: A
Explanation: (A) The childs weight supplies the countertraction for Bryants traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle.Both legs are suspended by skin traction. (B) The child in Bucks extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in '90 90' traction maintains both hips and knees at a90-degree flexion angle and the back is flat on the bed.
5. Right Answer: C
Explanation: (A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P s': pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
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