A neonate was admitted to the hospital with projectile vomiting. Accor

NCLEX RN Exam Questions

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Question 1 of 5.

A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.

A. Fluid volume deficit

B. Altered nutrition

C. Altered bowel elimination

D. Anxiety

Explanation: Fluid volume deficit is the major problem. Symptoms of dehydration are evident, and rehydration is critical to prevent life-threatening complications.

Question 2 of 5.

A client is diagnosed with stage II Hodgkin's lymphoma. The nurse recognizes that the client has involvement:

A. In a single lymph node or single site

B. In more than one node or single organ on the same side of the diaphragm

C. In lymph nodes on both sides of the diaphragm

D. In disseminated organs and tissues

Explanation: Stage II Hodgkin's lymphoma involves two or more lymph nodes or a single organ on the same side of the diaphragm, per the Ann Arbor staging system.

Question 3 of 5.

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

A. Drainage on the surgical dressing

B. Complaints of neck pain

C. Bleeding from the mouth

D. Swelling in the posterior neck

Explanation: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.

Question 4 of 5.

Which of the following combinations of foods is appropriate for an eight-month-old infant?

A. Cocoa-flavored cereal, orange juice, and strained meat

B. Graham crackers, strained prunes, and pudding

C. Rice cereal, bananas, and strained carrots

D. Mashed potatoes, strained beets, and whole milk

Explanation: Rice cereal, bananas, and strained carrots are developmentally appropriate, easily digestible foods for an eight-month-old, unlike the other options, which include choking hazards or inappropriate items like whole milk.

Question 5 of 5.

A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:

A. Serum glucose levels

B. Liver enzymes

C. Pancreatic enzymes

D. Plasma protein levels

Explanation: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is characterized by elevated liver enzymes, reflecting liver dysfunction.

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