NCLEX-RN
NCLEX RN Exam Questions
1. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
- A. Check vital signs.
- B. Massage the fundus.
- C. Offer a bedpan.
- D. Check for perineal lacerations.
Correct answer: Massage the fundus.
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
2. When admitting a 64-year-old patient with acute pancreatitis, the healthcare provider should specifically inquire about a history of
- A. diabetes mellitus.
- B. high-protein diet.
- C. cigarette smoking.
- D. alcohol consumption.
Correct answer: alcohol consumption.
Rationale: In patients with acute pancreatitis, alcohol consumption is a significant risk factor and one of the most common causes in the United States. It is crucial to assess alcohol intake as it plays a key role in the development of pancreatitis. While cigarette smoking, diabetes mellitus, and high-protein diets can contribute to various health issues, they are not directly associated with the development of acute pancreatitis.
3. Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
- A. Increased serum albumin level
- B. Decreased indirect bilirubin level
- C. Improved alertness and orientation
- D. Fewer episodes of bleeding varices
Correct answer: Fewer episodes of bleeding varices
Rationale: The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.
4. A client in the ICU has been intubated and placed on a ventilator. The physician orders synchronous intermittent mandatory ventilation (SIMV). Which statement best describes the work of this mode of ventilation?
- A. The ventilator delivers a set rate and tidal volume regardless of whether the client is attempting to breathe
- B. The ventilator coordinates delivered breaths with the client's respiratory efforts
- C. The ventilator provides a supplemental breath for every third breath of the client
- D. The ventilator provides breaths during the expiratory phase of the client's respirations
Correct answer: The ventilator coordinates delivered breaths with the client's respiratory efforts
Rationale: Synchronous intermittent mandatory ventilation (SIMV) is a ventilation mode that coordinates delivered breaths with the client's own respiratory efforts. This mode allows the client to initiate breaths, with the ventilator providing preset breaths at a controlled rate and volume. Option A is incorrect because in SIMV, the ventilator syncs with the client's respiratory efforts. Option C is incorrect as it does not accurately depict the way SIMV works. Option D is also incorrect as SIMV does not specifically provide breaths during the expiratory phase of the client's respirations. Therefore, the correct answer is B, where the ventilator coordinates breath delivery with the client's breathing efforts.
5. To palpate the liver during a head-to-toe physical assessment, the nurse should
- A. put pressure on the biopsy site using a sandbag
- B. elevate the head of the bed to facilitate breathing
- C. place the patient on the right side with the bed flat
- D. check the patient's post-biopsy coagulation studies
Correct answer: place the patient on the right side with the bed flat
Rationale: To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.
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