NCLEX-RN
NCLEX RN Exam Questions
1. A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
- A. Begin drug therapy within 72 hours of diagnosis
- B. Place the client in a positive-pressure room
- C. Initiate standard precautions
- D. Place the client in a negative-pressure room
Correct answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.
2. A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?
- A. Fever and rash
- B. Circumoral cyanosis
- C. Elevated glucose levels
- D. All of the above
Correct answer: A
Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.
3. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse should?
- A. place the patient on NPO status.
- B. assist the patient to lie flat in bed.
- C. ask the patient to empty the bladder.
- D. position the patient on the right side.
Correct answer: C
Rationale: To prepare a patient with ascites for paracentesis, the nurse should ask the patient to empty the bladder. This is important to decrease the risk of bladder perforation during the procedure. The patient should be positioned in Fowler's position to facilitate the procedure, not lie flat in bed, which can compromise breathing. Placing the patient on NPO status is unnecessary as sedation is not typically required for paracentesis. Positioning the patient on the right side is not a standard preparatory measure for paracentesis.
4. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?
- A. Nausea and vomiting
- B. Hypotonic bowel sounds
- C. Abdominal tenderness and guarding
- D. Muscle twitching and finger numbness
Correct answer: D
Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.
5. A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the healthcare provider?
- A. Asterixis and lethargy
- B. Jaundiced sclera and skin
- C. Elevated total bilirubin level
- D. Liver 3 cm below costal margin
Correct answer: A
Rationale: The most critical assessment data for the nurse to communicate to the healthcare provider in a patient with acute liver failure are asterixis and lethargy. These findings are indicative of grade 2 hepatic encephalopathy, which signals a rapid deterioration in the patient's condition, necessitating early transfer to a transplant center. Jaundiced sclera and skin, elevated total bilirubin level, and a liver 3 cm below the costal margin are all typical findings in hepatic failure but do not indicate an immediate need for a change in the therapeutic plan. Therefore, while these findings are relevant and should be reported, they are not as urgent as asterixis and lethargy in a patient with acute liver failure.
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