NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?
- A. Abdominal distention
- B. A bruit near the epigastric area
- C. 3 episodes of vomiting in the last hour
- D. Blood pressure of 160/90
Correct answer: B
Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.
2. When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?
- A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
- B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
- C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
- D. This is a question that should be directed to your healthcare provider.
Correct answer: C
Rationale: Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.
3. The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
- A. Chronic vessel plaque formation
- B. Pulmonary embolism
- C. Occlusions at the vessel bifurcations
- D. Coronary artery aneurysms
Correct answer: A
Rationale: The correct answer is chronic vessel plaque formation. Kawasaki Disease affects small and medium-sized blood vessels, leading to progressive inflammation and potential damage to the walls of medium-sized muscular arteries, which can result in coronary artery aneurysms. While other complications such as pulmonary embolism and occlusions at vessel bifurcations can occur in different conditions, for Kawasaki Disease, the primary concern is the development of chronic vessel plaque formation.
4. A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct answer: B
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
5. After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?
- A. Raise the siderails of the patient's bed
- B. Do not offer fluids, food, or any oral intake
- C. Check the temperature of the patient
- D. Teach the patient to avoid aspirin or NSAIDS
Correct answer: B
Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.
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