NCLEX Style Questions

The nurse is caring for a 9-month-old patient with GERD, who was brought to the clinic due to increased spitting up and irritability. Which of the following signs should the nurse monitor to assess the severity of the GERD?

• 1. Number of wet diapers per day

• 1. Occurrence of wheezing and coughing, especially at night

• Frequency of bowel movements

• 1. Level of physical activity

Answer explanation

The nurse should monitor the occurrence of wheezing and coughing, especially at night, to assess the severity of GERD in the 9-month-old patient.

The nurse is caring for a patient with community-acquired pneumonia. The patient presents with fever, productive cough, and pleuritic chest pain. Which of the following assessments should the nurse prioritize?

• 1. Checking blood glucose levels

• 1. Conducting a focused respiratory assessment and auscultating lung sounds

• 1. Measuring Sarah’s urine output

• 1. Assessing Sarah’s level of anxiety

Answer explanation

The nurse should prioritize conducting a focused respiratory assessment and auscultating lung sounds to assess the patient's pneumonia symptoms.

The nurse is caring for a 6-month-old infant with a suspected milk protein allergy. Which of the following symptoms should the nurse monitor to confirm this diagnosis?

• 1. Presence of blood in stool

• 1. Increased frequency of urination

• 1. Elevated blood pressure

• 1. Decreased appetite

Answer explanation

The nurse should monitor the presence of blood in stool to confirm a milk protein allergy in the 6-month-old infant.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is experiencing an exacerbation. Which of the following interventions should the nurse prioritize?

• 1. Administering a high-calorie diet

• 1. Providing supplemental oxygen therapy

• 1. Encouraging increased fluid intake

• 1. Monitoring blood glucose levels

Answer explanation

Providing supplemental oxygen therapy is the priority intervention for a COPD exacerbation to improve oxygenation and respiratory function.

The nurse is assessing a patient with suspected appendicitis. Which of the following findings would most likely indicate the need for immediate surgical intervention?

• 1. Low-grade fever

• 1. Rebound tenderness in the lower right quadrant

• 1. Increased appetite

• 1. Frequent urination

Answer explanation

Rebound tenderness in the lower right quadrant is a classic sign of appendicitis and indicates the need for immediate surgical intervention.

The nurse is caring for a patient with congestive heart failure (CHF). The patient presents with shortness of breath, edema, and fatigue. Which of the following assessments should the nurse prioritize?

• 1. Checking blood glucose levels

• 1. Monitoring daily weight and assessing for fluid retention

• 1. Measuring urine output

• 1. Assessing level of anxiety

Answer explanation

Monitoring daily weight and assessing for fluid retention is crucial in managing congestive heart failure (CHF) as it helps in evaluating the patient's fluid status and response to treatment.

The nurse is assessing a patient with suspected deep vein thrombosis (DVT). Which of the following findings would most likely indicate the need for immediate medical intervention?

• 1. Low-grade fever

• 1. Swelling and pain in the affected leg

• 1. Increased appetite

• 1. Frequent urination

Answer explanation

Swelling and pain in the affected leg is the most likely indication of DVT and requires immediate medical intervention.

The nurse is caring for a 2-year-old patient with asthma, who was brought to the clinic due to increased wheezing and coughing. Which of the following signs should the nurse monitor to assess the severity of the asthma?

• 1. Number of wet diapers per day

• 1. Occurrence of wheezing and coughing, especially at night

• 1. Frequency of bowel movements

• 1. Level of physical activity

Answer explanation

The nurse should monitor the occurrence of wheezing and coughing, especially at night, to assess the severity of the asthma in the 2-year-old patient.

The nurse is discharging a client newly diagnosed with Type 1 Diabetes. Which statement made by the client needs follow up?

• I will be sure to have a snack when exercising.

• I should check my blood sugar when I feel shaky

• I can control my blood sugar with diet

• I should get a medic alert bracelet in case of emergencies.