NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?
- A. The nail beds.
- B. The skin in the sacral area.
- C. The skin in the abdominal area.
- D. The membranes in the ear canal.
Correct answer: A
Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.
2. The healthcare provider is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?
- A. Name the year. What season is this? (pause for answer after each question)
- B. Subtract 7 from 100 and then subtract 7 from that. (pause for answer) Now continue to subtract 7 from the new number.
- C. I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen.
- D. What is this on my wrist? (point to your watch) Then ask, What is the purpose of it?
Correct answer: B
Rationale: The correct answer is to ask the client to perform a calculation that involves working memory and processing skills. This question not only assesses the recent memory but also evaluates attention and executive functioning. The choice 'I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen' assesses immediate recall rather than recent memory. Asking about the current year or season tests orientation rather than recent memory. Inquiring about the watch and its purpose assesses comprehension and judgment rather than recent memory.
3. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. An occupational therapist from the community center
- C. A physical therapist from the rehabilitation agency
- D. Another client with diabetes mellitus who takes insulin
Correct answer: B
Rationale: An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.
4. 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: Massage the fundus. 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. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.
5. The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?
- A. Reprimand the child and give a 15-minute 'time out'
- B. Maintain a permissive attitude for this behavior
- C. Use patience and a sense of humor to deal with this behavior
- D. Assert authority over the child through limit setting
Correct answer: C
Rationale: Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.
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