NCLEX NCLEX-RN
NCLEX RN Exam Prep
1. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
- A. Stage 1
- B. Stage 2
- C. Stage 3
- D. Stage 4
Correct answer: Stage 3
Rationale: The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
2. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:
- A. PT referral for development of a planned exercise program
- B. Avoidance of prolonged sun exposure
- C. Hot baths to promote muscle relaxation
- D. Instructions to evaluate the home environment to ensure safety
Correct answer: Hot baths to promote muscle relaxation
Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.
3. A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
- A. Norplant is safe and can be easily removed.
- B. Oral contraceptives should not be used by smokers.
- C. Depo-Provera is convenient with few side effects.
- D. The IUD provides protection against pregnancy and infection.
Correct answer: Oral contraceptives should not be used by smokers.
Rationale: The correct answer is that oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases the risk of cardiovascular problems, such as thromboembolic disorders. This is due to the combined effect of smoking and hormonal contraceptives. Choices A, C, and D are incorrect because they do not address the specific risk associated with smoking and oral contraceptives. Norplant's safety and ease of removal, Depo-Provera's convenience with few side effects, and the IUD's protection against pregnancy and infection are important points but not directly related to the increased risks for smokers using oral contraceptives.
4. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?
- A. Onset of labor in a pregnant woman
- B. Stroke
- C. Heart attack
- D. Migraine
Correct answer: Stroke
Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.
5. A client with asthma has low-pitched wheezes present in 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: Has increased airway obstruction.
Rationale: The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.
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