NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
- A. Start a peripheral IV
- B. Initiate high-quality chest compressions
- C. Establish an airway
- D. Obtain the crash cart
Correct answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.
2. The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
- A. I can expect yellow-green drainage from the incision for a few days.
- B. I can remove the bandages on my incisions tomorrow and take a shower.
- C. I should plan to limit my activities and not return to work for 4 to 6 weeks.
- D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.
Correct answer: B
Rationale: The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time. Choice A is incorrect as abnormal drainage should be reported. Choice C is incorrect as most patients can resume normal activities within a few days to a week. Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.
3. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
- A. Allergy to shellfish
- B. Apical pulse of 104
- C. Respiratory rate of 30
- D. Oxygen saturation of 90%
Correct answer: A
Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.
4. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct answer: A
Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.
5. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
- A. Assess the patient for nuchal rigidity
- B. Determine the patient's past exposure to infectious organisms
- C. Check the patient's WBC lab values
- D. Monitor for increased lethargy and drowsiness
Correct answer: D
Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.
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