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  1. Home
  2. NCLEX Certification
  3. NCLEX-RN Exam
  4. NCLEX.NCLEX-RN.v2024-01-19.q623 Dumps
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Question 326

A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:

Correct Answer: D
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important to monitor for continued change. (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
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Question 327

Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:

Correct Answer: A
(A) The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
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Question 328

A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction.
What tests should the nurse anticipate?

Correct Answer: D
Explanation/Reference:
Explanation:
(A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
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Question 329

When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

Correct Answer: A
Explanation
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol).
(D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
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Question 330

At her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it?

Correct Answer: C
Explanation
(A) At least eight glasses of fluid per day are encouraged to help dilute stomach contents, thereby decreasing irritation. (B) Alka Seltzer contains aspirin, which is irritating to gastric mucosa, and therefore should be avoided. (C) Small, frequent bland meals help to decrease gastric pressure and to prevent reflux. (D) Lying down after meals may cause gastric reflux and prevents optimal gastric emptying.
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