NCLEX-RN Practice Quiz Test Bank #1 (75 Questions) PDF

NCLEX-RN Practice Quiz Test Bank #1 (75 Questions) NCLEXRN-01-001 Question Tag: hypertension Question Category: Physiological Integrity, Reduction of Risk Potential Which individual is at greatest risk for developing hypertension? A. 45-year-old African-American attorney B. 60...

NCLEX-RN Practice Quiz Test Bank #1 (75 Questions) NCLEXRN-01-001 Question Tag: hypertension Question Category: Physiological Integrity, Reduction of Risk Potential Which individual is at greatest risk for developing hypertension? A. 45-year-old African-American attorney B. 60-year-old Asian-American shop owner C. 40-year-old Caucasian nurse D. 55-year-old Hispanic teacher Correct Answer: A: 45-year-old African American attorney Option A: African-Americans develop high blood pressure at younger ages than other groups in the US. Researchers have uncovered that African-Americans respond differently to hypertensive drugs than other groups of people. They are also found out to be more sensitive to salt, which increases the risk of developing hypertension. Option B: The incidence of hypertension in Asian-Americans does not appear to be significantly higher than the general population, according to limited US data. Option C: The racial disparity in hypertension and hypertension-related outcomes has been recognized for decades with African-Americans with greater risks than Caucasians. Option D: Hypertension prevalence rates in Hispanics may vary by gender and country of origin. Hispanic Americans overall have relatively low levels of hypertension, despite elevated levels of diabetes and obesity. NCLEXRN-01-002 Question Tag: acetaminophen Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? A. Gastric lavage B. Administer acetylcysteine (Mucomyst) orally C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open D. Have the patient drink activated charcoal mixed with water Correct Answer: A. Gastric lavage Option A: Acetaminophen overdose is extremely toxic to the liver causing hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting, abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs and may lead to death. Removing as much of the drug as possible is the first step in treatment for acetaminophen overdose, this is best done through gastric lavage. Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids and then aspirating the fluid back out. This procedure is done in life-threatening cases such as acetaminophen toxicity and only if less than one (1) hour has occurred after ingestion. Option B: The oral formulation of acetylcysteine is the drug of choice for the treatment of acetaminophen overdose but should be done after GI decontamination with activated charcoal. Liver damage is minimized by giving acetylcysteine (Mucomyst), the antidote for acetaminophen. Acetylcysteine reduces injury by substituting for depleted glutathione in the reaction that converts the toxic metabolite of acetaminophen to its nontoxic form. When given within 8 hours of acetaminophen toxicity, acetylcysteine is effective in preventing severe liver injury. It is administered orally or intravenously. Option C: Intermittent IV infusion with Dextrose 5% may be considered for late-presenting or chronic ingestion. Option D: Oral activated charcoal (AC) avidly adsorbs acetaminophen and may be administered if the patient presents within 1 hour after ingesting a potentially toxic dose. Charcoal should not be administered immediately before or with antidotes since it can effectively adsorb it and neutralize the benefits. NCLEXRN-01-003 Question Tag: cardiac catheterization Question Category: Safe and Effective Care Environment, Management of Care Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A. Angina at rest B. Thrombus formation C. Dizziness D. Falling blood pressure Correct Answer: B. Thrombus formation A thrombus formation may prevent blood from flowing normally through the circulatory system, which may become an embolism, and block the flow of blood towards major organs in the body. Option A: The reported incidence of myocardial infarction with angina at rest is less than 0.1%, and is mostly influenced by patient-related factors like the extent and severity of underlying cardiovascular-related diseases and technique- related factors. Options C & D: A falling BP and dizziness occur along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure. NCLEXRN-01-004 Question Tag: renal calculi, flank pain Question Category: Physiological Integrity, Basic Care and Comfort A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is: A. Maintain fluid and electrolyte balance B. Control nausea C. Manage pain D. Prevent urinary tract infection Correct Answer: C. Manage pain Managing pain is always a priority because it ultimately improves the quality of life. The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti- inflammatory drugs (NSAIDs). Option A: IV hydration in the setting of acute renal colic is controversial. Whereas some authorities believe that IV fluids hasten the passage of the stone through the urogenital system, others express concern that additional hydrostatic pressure exacerbates the pain of renal colic. Option B: Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. Several antiemetics have a sedating effect that is often helpful. Option D: Overuse of the more effective antibiotic agents leaves only highly resistant bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can result in potentially life-threatening urosepsis and pyonephrosis. NCLEXRN-01-005 Question Tag: growth, school age Question Category: Health Promotion and Maintenance What would the nurse expect to see while assessing the growth of children during their school age years? A. Decreasing amounts of body fat and muscle mass B. Little change in body appearance from year to year C. Progressive height increase of 4 inches each year D. Yearly weight gain of about 5.5 pounds per year Correct Answer: D. Yearly weight gain of about 5.5 pounds per year School age children gain about 5.5 pounds each year and increase about 2 inches in height. Between ages 2 to 10 years, a child will grow at a steady pace. Option A: Decreasing amounts of body fat and muscle mass are common in toddlers. Option B: A decrease in the change in body appearance occurs among young adults. Option C: Growth spurts are common in school-age children, as are periods of slow growth. NCLEXRN-01-006 Question Tag: blood pressure Question Category: Health Promotion and Maintenance At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to: A. Go get a blood pressure check within the next 15 minutes B. Check blood pressure again in two (2) months C. See the healthcare provider immediately D. Visit the health care provider within one (1) week for a BP check Correct Answer: A. Go get a blood pressure check within the next 15 minutes. The blood pressure reading is moderately high with the need to have it rechecked after a few minutes to verify. The client states it is ‘usually much lower.’ Thus a concern exists for complications such as stroke. Options B & D: Waiting 2 months or a week for follow-up is too long. Option C: Immediate check by the provider of care is not warranted. NCLEXRN-01-007 Question Tag: prioritization Question Category: Safe and Effective Care Environment, Safety and Infection Control The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago. C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with StevensJohnson syndrome that morning. D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago. Correct Answer: A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago. The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.  Option B: The client with antibiotic-induced diarrhea still needs continuous strict monitoring as the blood sugar levels may become unstable and dehydration is still possible. Option C: Stevens-Johnson syndrome (SJS) is a rare, serious disorder of the skin and mucous membranes. It’s usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters. Option D: Cellulitis is often an underestimated complication of HIV disease, but they are responsible for an appreciable morbidity. NCLEXRN-01-008 Question Tag: hypothyroidism, levothyroxine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:  A. Should be taken in the morning B. May decrease the client’s energy level C. Must be stored in a dark container D. Will decrease the client’s heart rate Correct Answer: A. Should be taken in the morning Option A: Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client’s sleeping pattern. Option B: Some of the side effects of Levothyroxine include hyperactivity and increase in heart rate. Option C: Keep this drug in a cool, dark, and dry place. Option D: A decrease in the heart rate is a desired effect of Levothyroxine. NCLEXRN-01-009 Question Tag: epiglottis Question Category: Physiological Integrity, Physiological Adaptation A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A. Prepare the child for X-ray of upper airways B. Examine the child’s throat C. Collect a sputum specimen D. Notify the healthcare provider of the child’s status Correct Answer: D. Notify the healthcare provider of the child’s status These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care. Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis. Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort. Option C: There are no indications for collection of sputum specimens. NCLEXRN-01-010 Question Tag: diabetes, school-age Question Category: Physiological Integrity, Physiological Adaptation In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? A. Polyphagia B. Dehydration C. Bedwetting D. Weight loss Correct Answer: C. Bedwetting One of the first symptoms of type 1 diabetes in children is bedwetting. Bedwetting in a school-age child is readily detected by the parents. Option A: Polyphagia or extreme hunger is one of the most common symptoms of diabetes both among adults and children.  Option B: Dehydration is not a symptom of type 1 diabetes, but it can be one of the many complications. Option D: Unintentional weight loss would develop gradually in a child with type 1 diabetes. NCLEXRN-01-011 Question Tag: pelvic inflammatory disease Question Category: Physiological Integrity, Physiological Adaptation A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A. Trichomoniasis B. Chlamydia C. Staphylococcus D. Streptococcus Correct Answer: B. Chlamydia Option B: Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease. Chlamydial bacteria could travel up toward the vagina or cervix into the reproductive organs. Option A: Trichomoniasis is a very common sexually transmitted disease, but it rarely predisposes to pelvic inflammatory disease. Option C & D: Staphylococcus and streptococcus may cause PID but it rarely occurs. NCLEXRN-01-012 Question Tag: prioritization Question Category: Safe and Effective Care Environment, Management of Care A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A. A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.” B. A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?” C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11, D. An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room. Correct Answer: C. An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10. Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. This client exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future. Option A: The client in option A might be experiencing an overdose. Option B: Client in option B is having withdrawal syndrome. Option D: The client in this option may experience a decrease in sensorium later on due to head trauma. NCLEXRN-01-013 Question Tag: coronary artery disease, nutrition Question Category: Health Promotion and Maintenance When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:  A. Eating three (3) balanced meals a day B. Adding complex carbohydrates C. Avoiding very heavy meals D. Limiting sodium to 7 gms per day Correct Answer: C. Avoiding very heavy meals Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. Too much plaque may accumulate in the arteries and block the delivery of blood and oxygen in major organs of the body. Option A: Eating a balanced diet should be a part of the management of a client with coronary artery disease. Option B: Complex carbohydrates decrease inflammation and help decrease the risk of plaque build up in the arteries. Option C: People with cardiovascular diseases should have a limit of less than 1.5 grams per day. NCLEXRN-01-014 Question Tag: morphine, pain management Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? A. The client complains of discomfort at the IV insertion site B. The client states “I just can’t get relief from my pain.” C. The level of drug is 100 ml at 8 AM and is 80 ml at noon D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon Correct Answer: C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon The minimal dose of 10 mL per hour which would be 40 mL given in a four (4) hour period. Only 60 mL should be left at noon. The pump is not functioning when more than expected medicine is left in the container. Option A: Discomfort at the IV insertion site may indicate inflammation or infection of the site. Option B: Morphine is a strong painkiller indicated for severe pain. Option D: The pump is working correctly if there is only 50 ml left at noon. NCLEXRN-01-015 Question Tag: health promotion, chiropractic treatment Question Category: Health Promotion and Maintenance The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? A. Electrical energy fields B. Spinal column manipulation C. Mind-body balance D. Exercise of joints Correct Answer: B. Spinal column manipulation The theory underlying chiropractic is that interference with transmission of mental impulses between the brain and body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation. Option A: Too much exposure to electrical energy can become a hazard to one’s health. Option C: Mind-body balance refers to yoga.  Option D: Low-impact aerobic exercises are easier on the joints but are not part of chiropractic medicine. NCLEXRN-01-016 Question Tag: neurological assessment, CVA Question Category: Physiological Integrity, Physiological Adaptation The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention? A. Decrease in level of consciousness B. Loss of bladder control C. Altered sensation to stimuli D. Emotional lability Correct Answer: A. Decrease in level of consciousness A further decrease in the level of consciousness may indicate increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal presence of a transient ischemic attack which may warn of impending thrombotic CVA. Option B: The patient post stroke may have transient urinary incontinence due to inability to communicate needs, or impaired motor and postural control. Control of the urinary sphincter may also be lost or diminished. Option C: Altered sensation to stimuli is expected for a patient post CVA. This may include sensory impairment to touch, loss of proprioception, difficulty interpreting visual, tactile, and auditory stimuli. Option D: Depression and anxiety are common responses by a patient after a catastrophic event such as in a stroke. Emotional lability (or pseudobulbar affect), refers to the involuntary and uncontrollable bursts of emotion without an emotional trigger. NCLEXRN-01-017 Question Tag: cystic fibrosis Question Category: Physiological Integrity, Physiological Adaptation A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A. Positive sweat test B. Bulky greasy stools C. Moist, productive cough D. Meconium ileus Correct Answer: C. Moist, productive cough Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with cystic fibrosis (CF). The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts, and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF. Option A: A positive sweat test is one of the indications of cystic fibrosis. Option B: A patient with CF experiences frequent greasy, bulky stools or difficulty with bowel movements as the thick mucus blocks the intestines. Option D: Meconium ileus is one of the early signs of CF. NCLEXRN-01-018 Question Tag: wound care Question Category: Physiological Integrity, Physical Adaptation The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should A. Place a call to the client’s health care provider for instructions B. Send him to the emergency room for evaluation C. Reassure the client’s wife that the symptoms are transient D. Instruct the client’s wife to call the doctor if his symptoms become worse Correct Answer: B. Send him to the emergency room for evaluation This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client’s best interest. Option A: Waiting to call for instructions may delay diagnosis of the patient. Option C: Reassuring the wife is incorrect since it is not a transient symptom. Option D: The symptoms are indicative of an emergency situation so the patient must be brought to the emergency department immediately. NCLEXRN-01-019 Question Tag: KUB radiograph Question Category: Physiological Integrity, Reduction of Risk potential Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test?  A. Client must be NPO before the examination B. Enema to be administered prior to the examination C. Medicate client with furosemide 20 mg IV 30 minutes prior to the examination D. No special orders are necessary for this examination Correct Answer: D. No special orders are necessary for this examination There are no special orders for this procedure, however, the client must be instructed of the general rule during radiography tests: remove any clothing, jewelry, or objects that may interfere with the test. Option A: There is no need to keep the client on NPO before the procedure. Option B: Enemas are not recommended for any type of radiograph test. Option C: Furosemide (Lasix) is unnecessary for this examination. NCLEXRN-01-020 Question Tag: myocardial infarction Question Category: Health Promotion and Maintenance The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question? A. “You need to regain your strength before attempting such exertion.” B. “When you can climb 2 flights of stairs without problems, it is generally safe.” C. “Have a glass of wine to relax you, then you can try to have sex.” D. “If you can maintain an active walking program, you will have less risk.” Correct Answer: B. “When you can climb 2 flights of stairs without problems, it is generally safe.” There is a risk of cardiac rupture at the point of the myocardial infarction for about six (6) weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by healthcare providers. Option A: The instruction in option A is vague and does not specifically tell the patient how to determine if the activity is already appropriate for him. Option C: Having a glass of wine is not recommended for a client who just had a myocardial infarction. Option D: Having an active walking program does not guarantee that the client has regained strength for a strenuous activity. NCLEXRN-01-021 Question Tag: triaging Question Category: Safe and Effective Care Environment, Management of Care A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A. A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying B. A teenager who got a singed beard while camping C. An elderly client with complaints of frequent liquid brown colored stools D. A middle-aged client with intermittent pain behind the right scapula Correct Answer: B. A teenager who got a singed beard while camping This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs have no nerve fibers so the client will not be aware of swelling.  Option A: When an infant is crying, the fontanels may look like they are bulging. Option C: The client in Option C can wait to be seen within the first hour. Option D: The client in Option D does not have a life-threatening condition but will still require immediate pain relief. NCLEXRN-01-022 Question Tag: toddler, developmental changes Question Category: Health Promotion and Maintenance While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs? A. “I want to protect my child from any falls.” B. “I will set limits on exploring the house.” C. “I understand the need to use those new skills.” D. “I intend to keep control over our child.” Correct Answer: C. “I understand the need to use those new skills.” Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment and develop autonomy. Option A: The statement in Option A is correct but pertains to the risks associated with a toddler. Option B: Setting limits on a toddler may cause frustration instead of independence. Option D: Controlling the child may be harmful to her development as toddlers should be developing their autonomy at this stage. NCLEXRN-01-023 Question Tag: enteral feeding, nasogastric feeding Question Category: Physiological Integrity, Basic Care and Comfort The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: A. Verify correct placement of the tube B. Check that the feeding solution matches the dietary order C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D. Ensure that feeding solution is at room temperature Correct Answer: A. Verify correct placement of the tube Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach. Option B: It is also important to check that the feeding solution matches the dietary order to ensure that the client gets proper nutrition. Option C: Aspirating the gastric contents is one of the methods used to determine the last feeding amount in the stomach, but is not the most important action the nurse should do. Option D: Keep it at room temperature so it would not upset the stomach. NCLEXRN-01-024 Question Tag: potassium, hyperkalemia Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A. Narrowed QRS complex B. Shortened “PR” interval C. Tall peaked “T” waves D. Prominent “U” waves Correct Answer: C. Tall peaked “T” waves A tall peaked T wave is a sign of hyperkalemia. The healthcare provider should be notified regarding discontinuing the medication. Option A: Narrow QRS complex indicates fast cardiac rhythms (generally more than 100 beats/min) with a QRS duration of 100 ms or less. Option B: A short PR interval (104o F [40o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”). Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chicken pox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal NCLEXRN-02-023 Question Tag: scarlet fever Question Category: Physiological Adaptation A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? A. Scarlet fever is caused by infection with group A Streptococcus bacteria. B. “Strawberry tongue” is a characteristic sign. C. Petechiae occur on the soft palate. D. The pharynx is red and swollen. Correct Answer: C. Petechiae occur on the soft palate. Petechiae on the soft palate are characteristic of rubella infection.  Option A: Bacteria called group A Streptococcus or group A strep cause scarlet fever. The bacteria sometimes make a poison (toxin), which causes a rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. The circulating toxin, produced by GABHS and often referred to as erythemogenic or erythrogenic toxin, causes the pathognomonic rash as a consequence of local production of inflammatory mediators and alteration of the cutaneous cytokine milieu. This results in a sparse inflammatory response and dilatation of blood vessels, leading to the characteristic scarlet color of the rash. Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous, exudative tonsils are typically observed if the infection originates in this area. Option D: The throat and tonsils may be very red and sore with scarlet fever, and swallowing may be painful. The mucous membranes usually are bright red, and scattered petechiae and small red papular lesions on the soft palate are often present. NCLEXRN-02-024 Question Tag: allergic reaction, diphenhydramine Question Category: Physiological Integrity, Pharmacological and Parenteral Therapy A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose? A. It is the correct dose B. The dose is too low C. The dose is too high D. The dose should be increased or decreased, depending on the symptoms Correct Answer: B. The dose is too low. This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore, the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician. Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, or the common cold. Diphenhydramine is also used to relieve coughs caused by minor throat or airway irritation. Option C: Diphenhydramine comes as a tablet, a rapidly disintegrating (dissolving) tablet, a capsule, a liquid-filled capsule, a dissolving strip, powder, and a liquid to take by mouth. When diphenhydramine is used for the relief of allergies, cold, and cough symptoms, it is usually taken every 4 to 6 hours. Option D: Before you give a diphenhydramine product to a child, check the package label to find out how much medication the child should receive. Give the dose that matches the child’s age on the chart. Ask the child’s doctor if you don’t know how much medication to give the child. NCLEXRN-02-025 Question Tag: undescended testis Question Category: Health Promotion and Maintenance The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate? A. Normally, the testes are descended by birth. B. The infant will likely require surgical intervention. C. The infant probably has only one testis. D. Normally, the testes descend by one year of age. Correct Answer: D. Normally, the testes descend by one year of age. Normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. The exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment. Option A: The testes usually descend by one year of age. Most of the time, a boy’s testicles descend by the time he is 9 months old. Undescended testicles are common in infants who are born early. The problem occurs less in fullterm infants. Option B: Surgical intervention is unnecessary; the testes descend by one year of age. The testicles will descend normally at puberty and surgery is not needed. Testicles that do not naturally descend into the scrotum are considered abnormal. An undescended testicle is more likely to develop cancer, even if it is brought into the scrotum with surgery. Cancer is also more likely in the other testicle. Option C: In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated. NCLEXRN-02-026 Question Tag: Wilms tumor Question Category: Physiological Integrity, Physiological Adaptation A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? A. The tumor is less than 3 cm. in size and requires no chemotherapy. B. The tumor did not extend beyond the kidney and was completely resected. C. The tumor extended beyond the kidney but was completely resected. D. The tumor has spread into the abdominal cavity and cannot be resected.