NCLEX-RN
NCLEX RN Exam Review Answers
1. 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.
2. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
- A. Assist the client in using the bedside commode
- B. Administer stool softeners daily as prescribed
- C. Administer antidysrhythmics PRN as prescribed
- D. Maintain the client on strict bed rest
Correct answer: B
Rationale: Administering stool softeners daily as prescribed is essential to prevent straining during defecation, which can lead to a Valsalva maneuver. Straining can increase intra-abdominal pressure, hinder venous return, and elevate blood pressure, risking cardiac complications in a client recovering from a heart attack. Using a bedside commode might be useful to minimize exertion during toileting but does not directly address the risk of a Valsalva maneuver. Administering antidysrhythmics PRN is not the primary intervention for preventing a Valsalva maneuver; these medications are used to manage dysrhythmias if they occur. Keeping the client on strict bed rest is not the best option as early mobilization is encouraged in post-myocardial infarction recovery to prevent complications such as deep vein thrombosis and muscle weakness.
3. After repair of an inguinal hernia, the infant is being cared for. Which assessment finding indicates that the surgical repair was effective?
- A. A clean, dry incision
- B. Abdominal distension
- C. An adequate flow of urine
- D. Absence of inguinal swelling with crying
Correct answer: D
Rationale: The absence of inguinal swelling when the infant cries or strains indicates that the surgical repair of the inguinal hernia was effective. Inguinal swelling typically occurs with crying or straining in cases of this condition. A clean, dry incision signifies the absence of wound infection post-surgery but does not directly indicate the effectiveness of the hernia repair. Abdominal distension suggests a gastrointestinal issue unrelated to the hernia repair. An adequate flow of urine is not specific to evaluating the success of inguinal hernia repair.
4. A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
- A. Ciprofloxacin (Cipro)
- B. Sulfonamide
- C. Norfloxacin (Noroxin)
- D. Nitro-Dur patch
Correct answer: D
Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing. Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.
5. Which of the following diseases or disorders is acute?
- A. Pneumonia
- B. Paralysis
- C. Alzheimer's disease
- D. Diabetes
Correct answer: A
Rationale: The correct answer is Pneumonia. Pneumonia is an acute illness characterized by inflammation of the air sacs in the lungs. It comes on suddenly and typically lasts for a short duration. Treatment can help cure pneumonia. Paralysis, Alzheimer's disease, and Diabetes are chronic conditions. Paralysis is the loss of muscle function in part of the body, usually permanent. Alzheimer's disease is a progressive brain disorder leading to memory loss and cognitive decline, and it is incurable. Diabetes is a chronic condition that affects how your body turns food into energy, and it requires lifelong management. Therefore, Pneumonia is the only acute condition among the options provided.
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