NCLEX-PN 400 practice questionsStudy online at client in the prenatal clinic pre-sents with a blood pressure read-ing of mm Hg, which is an elevation from last months read-ing of mm Hg. Which addi-tional sign or symptom suggests to the nurse that the clie

NCLEX-PN 400 practice questionsStudy online at https://quizlet.com/_bpxd831.A client in the prenatal clinic pre-sents with a blood pressure read-ing of 140/90 mm Hg, which is an elevation from last month's read-ing of 114/66 mm Hg. Which addi-tional sign or symptom suggests to the nurse that the client has mild preeclampsia?1.Headaches2.Generalized edema3.Weight gain of 10 pounds4.Trace amount of protein4.Trace amount of proteinRationale: Preeclampsia is considered mild when the diastolic blood pres-sure does not exceed 100 mm Hg and proteinuria is no more than 500 mg/day (trace to 1+). Symptoms such as headache, visual disturbances, or ab-dominal pain are typically absent with mild preeclampsia. Therefore, the only sign of mild preeclampsia from the op-tions given is a trace amount of pro-tein. A rapid weight gain and general-ized edema may occur. Headaches are present in severe preeclampsia.2.A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would ques-tion which intervention that is written in the plan?1.Palpate the abdomen for a mass.2.Check the urine for the presence of hematuria.3.Monitor the blood pressure for the presence of hypertension.4.Monitor the temperature for the presence of a kidney infection.1.Palpate the abdomen for a mass.Rationale: Wilms' tumor is an intraab-dominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipula-tion can cause seeding of the tumor and thus cause the spread of the cancer-ous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.3.The nurse is caring for a 58-year-old client with chronic kid-ney disease who is receiving peri-toneal dialysis. Which finding is considered most important by the nurse, requiring primary health care provider notification? Refer to chart.2. WBC 15,000 mm3Rationale: Peritonitis is the most com-mon complication of peritoneal dialysis and is often caused by a contamina-tion in the system. This infection can initially be determined by an increased WBC count. It can also include abdom-1 / 39

NCLEX-PN 400 practice questionsStudy online at https://quizlet.com/_bpxd83Vital Signs:Temperature: 99.2°F orallyHeart rate (HR): 96 beats per minuteBlood pressure (BP): 130/72 mm HgO2 saturation % on ABG: 94%Laboratory ResultsWhite blood cell (WBC) count: 15,000 cells/mLBlood glucose: 152 mg/dLPotassium: 5.2 mEq/LBlood urea nitrogen (BUN): 40 mg/dLDiagnostic ResultsChest x-ray: Mild atelectasisECG: First-degree heart blockCT scan of brain: Mild en-cephalopathy1.BUN: 40 mg/dL2.WBC 15,000 mm33.ECG: First-degree heart block4.Heart rate: 96 beats per minuteinal pain, cloudy peritoneal fluid, fever and chills, and nausea and vomiting.4.The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Viet-nam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole 1."It seems as if you or your daughter feel regret?"Rationale: The most therapeutic com-munication by the nurse is that which seeks to promote the client to reframe a situation. In option 2 the nurse uses trite social, nontherapeutic communica-tion. In option 3 the nurse uses false re-assurance, which is nontherapeutic. In 2 / 39

NCLEX-PN 400 practice questionsStudy online at https://quizlet.com/_bpxd83money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?1."It seems as if you or your daughter feel regret?"2."Oh well, we can only love our children, do our very best, and hope they reflect our upbringing."3."Don't blame yourself. You seem to have been very caring. Some people just turn out evil despite all we do for them."4."Do I hear you saying that you feel that your son's behavior was caused by the indulgence he re-ceived from his sister?"option 4 the nurse uses an inappropriate and inaccurate dynamic interpretation, which is insensitive.5.The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary reten-tion, knowing that these problems are likely caused by which situa-tion?1.Poor dietary choices2.Lack of exercise and poor diet3.Inadequate dietary intake and dehydration4.Psychomotor retardation and side effects of medication4.Psychomotor retardation and side ef-fects of medicationRationale: In this situation, urinary re-tention is most likely caused by medica-tions. Option 4 is the only option that ad-dresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.6.The nurse is encouraging a client to participate in recreational ther-apy. The client states that it is best to stay alone and not bother oth-ers. Which statement is an appro-1."Can you tell me more about your feel-ings?"Rationale: Clients who are possibly de-pressed may refuse to participate in pre-3 / 39

NCLEX-PN 400 practice questionsStudy online at https://quizlet.com/_bpxd83priate response from the nurse?1."Can you tell me more about your feelings?"2."I understand you are feeling negative, tell me more."3."Your primary health care provider (PHCP) has prescribed this so please go."4."I can't make you go, but you need to think of getting better and this is one way."scribed treatments including recreation-al therapy. A neutral statement that fo-cuses on the client is the best response to the client. This statement offers an opportunity for the client to detail con-cerns, and there is no judgment on the part of the nurse. Option 2 encourages the client to verbalize but is judgmen-tal. Option 3 cuts off the communication with falling back on prescribed activities. Option 4 involves giving advice and cuts off communication.7.The nursing student is car-ing for a client scheduled for cataract surgery. The student re-views the preoperative prescrip-tions with the nursing instruc-tor and notes that cyclopentolate eye drops are prescribed to be administered preoperatively. The unit nurse performed an admis-sion health assessment on the client before surgery. Which con-dition contraindicates using cy-clopentolate?1. Glaucoma2.Leukemia3.Liver disease4.Diabetes mellitus1. GlaucomaRationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic med-ication. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preop-erative mydriasis to dilate the eye. My-driatics are contraindicated in glaucoma because they can cause an increase in intraocular pressure.8.A client diagnosed with testicular cancer is prescribed cisplatin. The nurse would monitor for which toxic effect of this medication?1. Nausea2.Tinnitus2.TinnitusRationale: Cisplatin is a medication that can cause neurotoxicity, nephrotoxicity, bone marrow depression, and ototox-icity, which manifests as tinnitus and high-frequency hearing loss. Nausea 4 / 39