NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct answer: D
Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.
2. An infant with hydrocele is seen in the clinic for a follow-up visit at 1 month of age. The scrotum is smaller than it was at birth, but fluid is still visible on illumination. Which of the following actions is the physician likely to recommend?
- A. Massaging the groin area twice a day until the fluid is gone.
- B. Referral to a surgeon for repair.
- C. No treatment is necessary; the fluid is reabsorbing normally.
- D. Keeping the infant in a flat, supine position until the fluid is gone.
Correct answer: C
Rationale: A hydrocele is a collection of fluid in the scrotum that results from a patent tunica vaginalis. Illumination of the scrotum with a pocket light demonstrates the clear fluid. In most cases, the fluid reabsorbs within the first few months of life and no treatment is necessary. Massaging the groin area (Choice A) is not recommended as it will not help in the resolution of the hydrocele. Referral to a surgeon (Choice B) is not necessary at this stage since hydroceles often resolve on their own in infants. Keeping the infant in a flat, supine position (Choice D) does not aid in the reabsorption of fluid and is not a recommended intervention for hydrocele management.
3. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct answer: A
Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.
4. What would be the most appropriate follow-up by the home care nurse for a 57-year-old male client with a hemoglobin of 10 g/dl and a hematocrit of 32%?
- A. Ask the client if he has noticed any bleeding or dark stools
- B. Tell the client to call 911 and go to the emergency department immediately
- C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
- D. Tell the client to schedule an appointment with a hematologist
Correct answer: A
Rationale: The correct answer is to ask the client if he has noticed any bleeding or dark stools. Normal hemoglobin for males is 13.0 - 18 g/dl, and normal hematocrit for males is 42 - 52%. The values of hemoglobin and hematocrit provided for the client are below normal, indicating mild anemia. The first step for the nurse is to inquire about any signs of bleeding or changes in stools that could suggest bleeding from the gastrointestinal tract. This helps in assessing the possible cause of the low hemoglobin and hematocrit levels. The other options are not appropriate as calling 911 and going to the emergency department immediately is not warranted for mild anemia, scheduling a repeat test in 1 month delays addressing the current concern, and referring the client to a hematologist may be premature without investigating the cause of the low levels first.
5. A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?
- A. Skin has a purple/bluish color
- B. Capillary refill is 1 second
- C. Skin appears blanched at the pressure site
- D. Tenting appears when checking skin turgor
Correct answer: A
Rationale: When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.
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