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 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.
3. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?
- A. Dry palpebral and oral mucosa
- B. Crackles at bilateral lung bases
- C. Temperature 100.8?F (38.2?C)
- D. No bowel movement for 4 days
Correct answer: C
Rationale: The correct answer is the patient's temperature of 100.8�F (38.2�C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.
4. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct answer: A
Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces.
5. Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
- A. Advise limiting alcohol intake to 1 drink daily
- B. Schedule for liver cancer screening every 6 months
- C. Initiate administration of the hepatitis C vaccine series
- D. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually
Correct answer: B
Rationale: Patients diagnosed with chronic hepatitis B are at a higher risk for developing liver cancer. Therefore, it is essential to schedule them for liver cancer screening every 6 to 12 months to detect any potential malignancies at an early stage. Advising patients to limit alcohol intake is crucial as alcohol can exacerbate liver damage; thus, patients with chronic hepatitis B are advised to completely avoid alcohol. Administering the hepatitis C vaccine is irrelevant for a patient diagnosed with chronic hepatitis B since it is a different virus. Monitoring anti-hepatitis B surface antigen (anti-HBs) levels annually is not necessary as the presence of anti-HBs indicates a past hepatitis B infection or vaccination, and it does not require regular monitoring.
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