a systemic sign of infection is
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Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. A systemic sign of infection is ______________.

Correct answer: D

Rationale: The correct answer is 'a lack of appetite.' When a person experiences a systemic infection, they may exhibit signs that affect the entire body. A lack of appetite is a common systemic sign of infection, along with other symptoms like rapid pulse, fever, and an elevated white blood cell count. Swelling, redness, and heat are more indicative of localized inflammation or infection, rather than systemic involvement.

2. A client on lithium has diarrhea and vomiting. What should the nurse do first?

Correct answer: D

Rationale: Diarrhea and vomiting are manifestations of lithium toxicity. The priority action for the nurse is to hold the next dose of lithium and obtain an order for a stat serum lithium level to confirm toxicity. This ensures patient safety and prevents further harm. Recognizing it as a drug interaction is not the first step in this scenario. Cogentin is used to manage extrapyramidal symptoms (EPS) associated with antipsychotics, not lithium toxicity. Reassuring the client about these symptoms as common side effects of lithium therapy is inappropriate as they indicate a more serious issue than typical side effects like hand tremors, nausea, polyuria, and polydipsia.

3. A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?

Correct answer: A

Rationale: The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.

4. A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:

Correct answer: B

Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.

5. Which of the following conditions increases a client's risk of aspiration of stomach contents?

Correct answer: A

Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.

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