NCLEX-RN
NCLEX RN Exam Prep
1. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is:
- A. Hesitancy
- B. Oliguria
- C. Retention
- D. Urgency
Correct answer: A
Rationale: Urinary hesitancy occurs when a client has difficulty starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. Oliguria refers to decreased urine output, retention is the inability to empty the bladder fully, and urgency is the sudden and strong need to urinate.
2. A patient suffering from hyperglycemia would be experiencing:
- A. Low blood sugar
- B. High blood sugar
- C. Normal blood sugar
- D. None of the above
Correct answer: B
Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.
3. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says, "I took too many diet pills"? and "my heart feels like it is racing out of my chest."?
- B. A young adult who says, "I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?"?
- C. An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 11.
- D. An elderly client who reports having taken a "large crack hit"? 10 minutes prior to walking into the emergency room.
Correct answer: C
Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.
4. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
- A. This too shall pass.
- B. Take the child immediately to the ER
- C. Contact the Poison Control Center quickly
- D. Give the child syrup of ipecac
Correct answer: C
Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.
5. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or healthcare providers, the nurse emphasizes interventions that do which of the following? (Berman & Snyder, 2012, p. 713)
- A. Eliminate the reservoir
- B. Block the portal of exit from the reservoir
- C. Block the portal of entry into the host
- D. Decrease the susceptibility of the host
Correct answer: B
Rationale: To prevent the spread of infection from a chronic carrier, the nurse should focus on blocking the portal of exit from the reservoir, which is the carrier person. By preventing the movement of the organism from the reservoir, the infection can be contained. Eliminating the reservoir is not feasible in this case as the carrier is a chronic carrier. Blocking the portal of entry into the host or decreasing the susceptibility of the host would only impact individual prevention and not the spread from the carrier to others.
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