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. Why is it important to genotype HCV before initiating drug therapy?
- A. Side effects of nucleotide analogs
- B. Measures for improving the appetite
- C. Ways to increase activity and exercise
- D. Administering alpha-interferon (Intron A)
Correct answer: B
Rationale: Genotyping of HCV plays a crucial role in managing treatment as it helps determine the most effective therapy for the specific viral strain. It allows healthcare providers to personalize treatment regimens and predict response rates. The statement about acute HCV infection converting to chronic state is accurate, highlighting the need for appropriate management. Immune globulin and vaccines are not available for HCV, and Ribavirin is commonly used for chronic HCV infection. Improving appetite is essential in liver health as adequate nutritional intake supports hepatocyte regeneration. Choices A, C, and D are incorrect as they do not address the specific importance of genotyping in HCV treatment or the significance of appetite improvement in liver function.
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. What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- A. Acute pain related to biologic and chemical factors
- B. Anxiety related to change in or threat to health status
- C. Hopelessness related to deteriorating physiological condition
- D. Risk for side effects related to medical therapy
Correct answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life. Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
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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