NCLEX NCLEX-RN
NCLEX RN Exam Questions
1. A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?
- A. Fever and rash
- B. Circumoral cyanosis
- C. Elevated glucose levels
- D. All of the above
Correct answer: Fever and rash
Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.
2. The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to:
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct answer: Progressive placental insufficiency
Rationale: A postmature or postterm pregnancy occurs when a pregnancy exceeds the typical term of 38 to 42 weeks. In this situation, the fetus is at risk due to progressive placental insufficiency. This occurs because the placenta loses its ability to function effectively after 42 weeks. The accumulation of calcium deposits in the placenta reduces blood perfusion, oxygen supply, and nutrient delivery to the fetus, leading to potential growth problems. Choices A, B, and C are incorrect because excessive fetal weight, low blood sugar levels, and depletion of subcutaneous fat are not the primary risks associated with postmature fetuses. The main concern lies in the compromised placental function and its impact on fetal well-being.
3. Why should direct care providers avoid glued-on artificial nails?
- A. Interfere with dexterity of the fingers.
- B. Could fall off in a patient’s bed.
- C. Harbor microorganisms.
- D. Can scratch a patient.
Correct answer: Harbor microorganisms.
Rationale: Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.
4. A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- A. Monitor for fever every 4 hours.
- B. Require visitors to wear respiratory masks and protective clothing.
- C. Consider transfusion of packed red blood cells.
- D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct answer: Check for signs of bleeding, including examination of urine and stool for blood.
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.
5. A daughter of a Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter’s behavior reflect?
- A. Prejudice
- B. Stereotyping
- C. Assimilation
- D. Ethnocentrism
Correct answer: Assimilation
Rationale: The correct answer is assimilation. Assimilation involves incorporating the behaviors of a dominant culture. In this scenario, maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike, which is not demonstrated by the daughter's behavior. Ethnocentrism is the perception that one’s beliefs are superior to those of others, which is not evident in this situation.
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