NCLEX-RN
NCLEX RN Exam Questions
1. The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?
- A. The patient complains of right upper-quadrant pain upon palpation.
- B. The patient's hands flap back and forth when the arms are extended.
- C. The patient has ascites and a 2-kg weight gain from the previous day.
- D. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
Correct answer: B
Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.
2. 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.
3. A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
- A. Hemoglobin of 11 g/dl
- B. Platelet count of 150,000
- C. INR of 2.5
- D. Potassium of 2.7 mEq/L
Correct answer: D
Rationale: The critical lab result that should be reported to the physician immediately in this case is the potassium level of 2.7 mEq/L. A potassium imbalance, especially in a patient with a history of dysrhythmia like atrial fibrillation, can be life-threatening and lead to cardiac distress. Low potassium levels (hypokalemia) can predispose the patient to dangerous arrhythmias, including worsening atrial fibrillation. Hemoglobin of 11 g/dl, platelet count of 150,000, and an INR of 2.5 are within acceptable ranges and not as immediately concerning as a low potassium level in this clinical context.
4. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?
- A. antibody to hepatitis D (anti-HDV).
- B. hepatitis B surface antigen (HBsAg).
- C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
- D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Correct answer: D
Rationale: Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.
5. A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take?
- A. Administer both drugs.
- B. Administer the spironolactone.
- C. Withhold the spironolactone and administer the furosemide.
- D. Withhold both drugs until discussed with the healthcare provider.
Correct answer: B
Rationale: A serum potassium level of 3.2 mEq/L is low (hypokalemia), which can be concerning in a patient with cirrhosis who is already at risk for electrolyte imbalances. Spironolactone is a potassium-sparing diuretic that can help increase the patient's potassium level and correct the hypokalemia. Therefore, the appropriate action for the nurse to take in this scenario is to administer the spironolactone. Withholding the spironolactone could further lower the potassium level. Furosemide, on the other hand, is a loop diuretic that can lead to potassium loss and worsen hypokalemia; hence, it should be withheld until the nurse discusses the situation with the healthcare provider. While the healthcare provider should be informed about the low potassium value, immediate administration of spironolactone is necessary to address the hypokalemia in this patient population.
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