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1. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
- A. Imbalanced nutrition: Less than body requirements
- B. Chronic low self-esteem
- C. Risk for suicide
- D. Hopelessness
Correct answer: Risk for suicide
Rationale: The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
2. During a scheduled health maintenance visit, which common source of stress for a 6-year-old client would the nurse include in the teaching session?
- A. Wanting to be first
- B. Demanding privacy
- C. Having a desire to be like an idol
- D. Being more selective with playmates
Correct answer: Wanting to be first
Rationale: A common source of stress for a 6-year-old school-age client is competition, such as wanting to be first or the best (winning). This aspect can create stress for a 6-year-old as they navigate social interactions and activities. Therefore, the nurse would address this issue during the teaching session at the health maintenance visit. Demanding privacy, having a desire to be like an idol, and being more selective with playmates are characteristics more commonly associated with 7-year-old clients, not typically seen in the stressors of a 6-year-old. Understanding age-appropriate stressors is crucial for providing tailored education and support in pediatric care.
3. A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?
- A. The patient reports no chest pain.
- B. Blood pressure is 140/90 mm Hg
- C. Stools test negative for occult blood.
- D. The apical pulse rate is 68 beats/minute.
Correct answer: Stools test negative for occult blood.
Rationale: The best indicator that propranolol has been effective in a patient with cirrhosis and esophageal varices is when the stools test negative for occult blood. Propranolol is prescribed to decrease the risk of bleeding from esophageal varices. This medication's effectiveness is primarily assessed by the absence of blood in the stools, indicating a reduction in the risk of bleeding from the varices. Monitoring for chest pain, blood pressure control, and a decrease in heart rate are important parameters in other conditions treated with propranolol, such as hypertension, angina, and tachycardia, but in this particular case, the absence of occult blood in the stools is the most relevant indicator of treatment success.
4. A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
- A. IgA
- B. IgD
- C. IgE
- D. IgG
Correct answer: IgG
Rationale: IgG is the only immunoglobulin that can cross the placental barrier, providing passive immunity to the fetus. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are generated after an initial exposure to an antigen, offering long-term protection against microorganisms. IgG antibodies are critical for protecting the fetus as they can be rapidly reproduced upon re-exposure to the same antigen. IgA is primarily found in mucosal areas, IgD is involved in antigen recognition, and IgE is associated with allergic reactions, but they do not provide the same level of protection to the fetus as IgG.
5. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
- A. Altered tissue perfusion
- B. Risk for fluid volume deficit
- C. High risk for hemorrhage
- D. Risk for infection
Correct answer: Risk for infection
Rationale: The correct answer is 'Risk for infection.' When membranes are ruptured for over 24 hours before delivery, there is a significantly increased risk of infection for both the mother and the newborn. Factors such as increased local cytokines, an imbalance in enzyme activity, and increased intrauterine pressure contribute to this risk. 'Altered tissue perfusion' is not the priority in this scenario as there is no indication of compromised blood flow. 'Risk for fluid volume deficit' is not the priority as there are no signs of excessive fluid loss. 'High risk for hemorrhage' is not the priority as the question does not suggest active bleeding as an immediate concern.
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