NCLEX-RN
NCLEX RN Exam Questions
1. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
- A. Expose the cast to air and turn the child frequently.
- B. Use a heat lamp to reduce the drying time.
- C. Handle the cast with the abductor bar.
- D. Turn the child as little as possible.
Correct answer: A
Rationale: After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.
2. 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: B
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.
3. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?
- A. Administer hepatitis B vaccine.
- B. Test for antibodies to hepatitis B.
- C. Teach about alpha-interferon therapy.
- D. Give hepatitis B immune globulin.
Correct answer: C
Rationale: In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.
4. During a physical exam, a healthcare professional assisting a client suspected of having meningitis bends the client's leg at the hip to a 90-degree angle. When attempting to extend the leg at the knee, the client experiences severe pain. What type of test is being performed?
- A. Brudzinski's sign
- B. Romberg's sign
- C. Kernig's sign
- D. Babinski's sign
Correct answer: C
Rationale: The healthcare professional is performing Kernig's sign, a test for meningeal irritation often seen in meningitis cases. Kernig's sign involves bending the client's leg at a 90-degree angle at the hip and then attempting to extend the leg at the knee. Severe pain during this maneuver indicates a positive Kernig's sign, suggesting irritation of the meningeal membranes. Brudzinski's sign involves flexing the neck causing involuntary flexion of the hips and knees; Romberg's sign assesses balance and proprioception; Babinski's sign checks for abnormal reflexes in the foot.
5. A 34-year-old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the healthcare provider before administration?
- A. Ribavirin (Rebetol, Copegus) 600 mg PO bid
- B. Pegylated ?-interferon (PEG-Intron, Pegasys) SQ weekly
- C. Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
- D. Dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea
Correct answer: B
Rationale: The correct answer is B: Pegylated ?-interferon (PEG-Intron, Pegasys) SQ weekly. Pegylated ?-interferon is typically administered once weekly, not daily. Therefore, this medication requires further discussion with the healthcare provider before administration to ensure the correct dosing frequency. Ribavirin, choice A, is appropriate for chronic hepatitis C treatment. Choices C and D, Diphenhydramine and Dimenhydrinate, are commonly used for symptomatic relief in patients with hepatitis C and do not require further discussion with the healthcare provider in this context.
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