NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. A client had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct answer: C
Rationale: A prickling sensation in the right hand is indicative of compartment syndrome, a serious condition that can lead to tissue damage and impaired circulation. Immediate attention is required to prevent complications. Capillary refill of 3 seconds, warm and normally colored skin, and slight swelling of fingers are expected findings after a closed reduction and casting. These findings do not typically indicate a critical issue and can be managed with routine monitoring.
2. A 7-year-old child is seen in a clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. What information should the nurse provide to the parents?
- A. Nighttime (nocturnal) enuresis does not respond to treatment.
- B. Nighttime (nocturnal) enuresis is caused by a psychiatric problem.
- C. Nighttime (nocturnal) enuresis requires surgical intervention to improve the problem.
- D. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.
Correct answer: D
Rationale: Nighttime (nocturnal) enuresis is common in children and is characterized by a child who has never been dry at night for extended periods. Most children eventually outgrow bedwetting without therapeutic intervention. This condition is due to the child being unable to sense a full bladder and not awakening to void, often related to delayed maturation of the central nervous system. It is important for parents to understand that nighttime (nocturnal) enuresis is not caused by a psychiatric problem, does not typically require surgical intervention, and usually resolves on its own over time.
3. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
4. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Teach the patient about the need for fluid intake.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct answer: A
Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.
5. When analyzing the results of the urinalysis collected preoperatively from a child with epispadias scheduled for surgical repair, which finding should the nurse most likely expect to note?
- A. Hematuria
- B. Proteinuria
- C. Bacteriuria
- D. Glucosuria
Correct answer: C
Rationale: Epispadias is a congenital defect characterized by the abnormal placement of the urethral orifice of the penis, often on the dorsum. This anatomical anomaly predisposes individuals to bacterial entry into the urinary tract, leading to bacteriuria. Hematuria, proteinuria, and glucosuria are not typically associated with epispadias. Hematuria refers to the presence of blood in the urine, proteinuria indicates protein in the urine, and glucosuria is the presence of glucose in the urine, none of which are commonly seen in epispadias.
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