NCLEX NCLEX-RN
NCLEX RN Exam Questions
1. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?
- A. antibody to hepatitis D (anti-HDV).
- B. hepatitis B surface antigen (HBsAg).
- C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
- D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Correct answer: anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Rationale: Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.
2. Which of the following items of subjective client data would be documented in the medical record by the nurse?
- A. Client's face is pale
- B. Cervical lymph nodes are palpable
- C. Nursing assistant reports client refused lunch
- D. Client feels nauseated
Correct answer: Client feels nauseated
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
3. The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?
- A. Wound care
- B. Pain control measures
- C. Measurement of intake
- D. Cold and heat applications
Correct answer: Wound care
Rationale: Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.
4. A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
- A. 5 mm/hr
- B. 12 mm/hr
- C. 28 mm/hr
- D. 40 mm/hr
Correct answer: 40 mm/hr
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
5. The categories such as ethnicity, gender, and religion illustrate which concept?
- A. Family
- B. Cultures
- C. Spirituality
- D. Subcultures
Correct answer: Subcultures
Rationale: Within cultures, various groups of people share different beliefs, values, and attitudes due to factors such as ethnicity, religion, education, occupation, age, and gender. When these distinct groups coexist within a broader culture, they are referred to as subcultures. While ethnicity, gender, and religion are important components of individuals' identities, they do not represent the concepts of family, cultures, or spirituality. The correct answer is 'Subcultures' as these categories reflect differences within a larger cultural context, emphasizing the unique characteristics shared by members of subcultural groups.
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