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NCLEX RN Exam Review Answers
1. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?
- A. INR is 3 seconds long
- B. Heart rate is 110 beats per minute
- C. Intracranial Pressure is 22 mmHg
- D. Blood pressure is 140/80
Correct answer: Intracranial Pressure is 22 mmHg
Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.
2. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do?
- A. Contact the provider
- B. Ask the child to write their name on paper
- C. Ask a coworker about the identification of the child
- D. Ask the father who is in the room the child’s name
Correct answer: Ask the father who is in the room the child’s name
Rationale: When encountering a non-verbal child without identification, it is appropriate for the nurse to ask the accompanying parent or guardian for the child's name. The father, being present in the room, can provide the necessary information. This ensures accurate identification to deliver the correct medication. Contacting the provider may cause unnecessary delays. Asking a non-verbal child to write their name is not feasible. Asking a coworker may not provide reliable identification as they may not have direct knowledge.
3. Based on the information given, which patient would be an appropriate candidate for a closed MRI without contrast?
- A. A 20-year-old woman with unexplained joint pain and a low BMI.
- B. A 35-year-old woman with Multiple Sclerosis who is trying to conceive.
- C. A 67-year-old man who had open-heart surgery 4 years ago.
- D. A 40-year-old woman in a hypomanic state for the last 2 days.
Correct answer: A 20-year-old woman with unexplained joint pain and a low BMI.
Rationale: The correct answer is the 20-year-old woman with unexplained joint pain and a low BMI. MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI. Choice B is incorrect because using MRI without contrast may not be ideal for a patient trying to conceive. Choice C is incorrect as the patient’s past open-heart surgery may pose risks for an MRI without contrast. Choice D is incorrect since the patient's hypomanic state does not indicate a need for an MRI without contrast for joint pain.
4. During an intake screening for a patient with hypertension who has been taking ramipril for 4 weeks, which statement made by the patient would be most important for the nurse to pass on to the physician?
- A. ''I get dizzy when I get out of bed.''
- B. ''I'm urinating much more than I used to.''
- C. ''I've been running on the treadmill for 10 minutes each day.''
- D. ''I can't get rid of this cough.''
Correct answer: ''I can't get rid of this cough.''
Rationale: The correct answer is ''I can't get rid of this cough.'' Ramipril, an ACE inhibitor, commonly causes a persistent, dry cough as an adverse effect. This symptom can be indicative of bradykinin accumulation caused by ACE inhibitors. It is important for the nurse to inform the physician about this side effect so that a medication change to another class of antihypertensives, such as an ARB, may be considered. Choices A, B, and C are not directly related to the common adverse effects of ramipril and are not as concerning for a patient on this medication.
5. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
- A. Get the nurse who is caring for the patient.
- B. Tell the nurse that the patient has had another seizure.
- C. Observe the patient for any injuries and call out for help.
- D. Nothing. This patient is not one of your assignments.
Correct answer: Observe the patient for any injuries and call out for help.
Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.
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