NCLEX-RN
NCLEX RN Exam Questions
1. Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
- A. The patient's urine is bright yellow
- B. The patient's stools are tan colored
- C. The patient has increased pain after eating
- D. The patient complains of chronic heartburn
Correct answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
2. What is a priority problem for a child with severe edema caused by nephrotic syndrome?
- A. Risk for constipation
- B. Risk for skin breakdown
- C. Inability to regulate body temperature
- D. Consuming more calories or nutrients than the body requires
Correct answer: B
Rationale: In nephrotic syndrome, characterized by massive proteinuria, hypoalbuminemia, and edema, a child with severe edema is at high risk for skin breakdown. The priority concern is to prevent skin breakdown by cleaning skin surfaces and ensuring adequate separation with clothing to avoid irritation. The child with nephrotic syndrome is typically anorexic, making consuming more calories or nutrients than necessary not a concern. Risk for constipation and inability to regulate body temperature are not primary issues associated with edema caused by nephrotic syndrome.
3. A home care nurse instructs the mother of a 5-year-old child with lactose intolerance about dietary measures for her child. The nurse should tell the mother that it is necessary to provide which dietary supplement in the child's diet?
- A. Fats
- B. Zinc
- C. Protein
- D. Calcium
Correct answer: D
Rationale: In lactose intolerance, the inability to digest lactose, the sugar in dairy products, can lead to calcium deficiency if dairy products are removed from the diet. Calcium is crucial for bone health and other bodily functions, so alternative calcium sources like fortified non-dairy milks or leafy greens must be included to prevent deficiency. While fats and proteins are important nutrients, they are not typically deficient in lactose intolerance. Zinc, although an essential mineral, is not the primary concern in this case.
4. A man has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?
- A. Vertigo
- B. Hypotension
- C. Palpitations
- D. Nagging, dry cough
Correct answer: B
Rationale: The correct answer is 'Hypotension.' Lisinopril, an ACE inhibitor commonly used for CHF, can cause hypotension as a side effect. Persistent diarrhea can lead to dehydration, increasing the risk of hypotension in this patient. Vertigo (choice A) is not a typical side effect of lisinopril. Palpitations (choice C) are not directly associated with lisinopril use. A nagging, dry cough (choice D) is a common side effect of ACE inhibitors like lisinopril, but in this case, the patient's presentation with persistent diarrhea would make hypotension a more immediate concern.
5. A client in end-stage renal disease is receiving peritoneal dialysis at home. The nurse must educate the client about potential complications associated with this procedure. All of the following are complications associated with peritoneal dialysis EXCEPT:
- A. Hypotriglyceridemia
- B. Abdominal hernia
- C. Anorexia
- D. Peritonitis
Correct answer: A
Rationale: Peritoneal dialysis poses risks of various complications, including abdominal hernia, anorexia, peritonitis, and other issues. However, hypotriglyceridemia is not a common complication associated with peritoneal dialysis. The nurse should focus on educating the client about the risks of developing peritonitis, abdominal hernias, anorexia, low back pain, and abdominal bleeding. Monitoring triglyceride levels is essential for managing lipid disorders but is not directly linked to peritoneal dialysis complications.
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