NCLEX NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. A healthcare professional is preparing to palpate and percuss a patient's abdomen as part of the assessment process. Which of these findings would cause the healthcare professional to immediately discontinue this part of the assessment?
- A. The patient states, 'That sounds like it might hurt me.'
- B. There is a pulsating mass on the upper middle abdomen.
- C. The patient has black, tarry stools and anemia.
- D. The patient has had an endoscopic procedure two days prior.
Correct answer: There is a pulsating mass on the upper middle abdomen.
Rationale: A pulsating mass on the upper middle abdomen is indicative of a life-threatening aortic aneurysm. Palpating or percussing such an area can potentially cause the aneurysm to rupture, leading to severe internal bleeding and endangering the patient's life. Therefore, the healthcare professional should immediately discontinue the assessment to prevent any harm.\nChoice A is incorrect because the patient expressing concerns about the procedure does not necessarily indicate a life-threatening condition. Choice C describes symptoms that should be further investigated but do not pose an immediate threat during abdominal assessment. Choice D, a prior endoscopic procedure, is not a contraindication for palpation or percussion of the abdomen unless there are specific complications or conditions related to the procedure that would require caution.
2. A patient is getting discharged from a skilled nursing facility (SNF). The patient has a history of severe COPD and PVD. The patient is primarily concerned about his ability to breathe easily. Which of the following would be the best instruction for this patient?
- A. Deep breathing techniques to increase oxygen levels.
- B. Cough regularly and deeply to clear airway passages.
- C. Cough following bronchodilator utilization.
- D. Decrease CO2 levels by increasing oxygen intake during meals.
Correct answer: Cough following bronchodilator utilization.
Rationale: The correct answer is to instruct the patient to cough following bronchodilator utilization. In COPD and PVD patients, bronchodilators help to open up the airways, making coughing more effective in clearing secretions from the lungs. This instruction can aid in improving the patient's ability to breathe by enhancing airway clearance. Deep breathing techniques (Choice A) may help increase oxygen levels but may not directly address the patient's immediate concern of breathing difficulty. Coughing regularly and deeply (Choice B) can be beneficial, but the timing following bronchodilator use is more crucial to maximize its effectiveness. Decreasing CO2 levels by increasing oxygen intake during meals (Choice D) does not directly address the patient's concern about breathing ease or the role of bronchodilators in improving cough effectiveness.
3. Which of the following patients is at the greatest risk for a stroke?
- A. A 60-year-old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past
- B. A 75-year-old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic
- C. A 40-year-old female who has high cholesterol and uses oral contraceptives
- D. A 65-year-old female who is African American, has sickle cell disease, and smokes cigarettes
Correct answer: A 60-year-old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past
Rationale: The correct answer is the 60-year-old male who has a combination of significant risk factors for stroke, including atrial fibrillation, a history of a transient ischemic attack (TIA), and obesity. These factors greatly increase his risk of stroke. While other choices may have some individual risk factors, they do not collectively pose as high a risk as the patient described in option A. Option B includes migraines and alcohol consumption but lacks other major risk factors seen in option A. Option C mentions high cholesterol and oral contraceptives, which are risk factors but not as significant as atrial fibrillation and a prior TIA. Option D includes smoking and sickle cell disease but lacks the crucial risk factors present in option A.
4. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse prioritize first on the list to be discharged in order to make a room available for a new admission?
- A. A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
- B. A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
- C. An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
- D. An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
Correct answer: A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago.
Rationale: The best candidate for discharge during a need for emergency room availability is a stable patient with a chronic condition who is familiar with their care. In this scenario, the middle-aged client in option A, who has been ventilator dependent for over seven years and admitted with bacterial pneumonia five days ago, is most suitable for discharge. This client is likely stable and can continue medication therapy at home, making them the most appropriate choice for discharge at this time. Choice B should not be the priority for discharge as the young adult with diabetes mellitus Type 2 admitted with antibiotic-induced diarrhea 24 hours ago may need further monitoring and management of their condition. Choice C, the elderly client with multiple comorbidities and admitted with Stevens-Johnson syndrome on the same day, is not a suitable candidate for immediate discharge as they may require ongoing medical attention and observation. Choice D, the adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago, should not be discharged first as acute cellulitis may require continued treatment and monitoring, especially in the context of a positive HIV status.
5. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not already completed, would take priority over the others?
- A. Place the patient in a 90-degree position
- B. Assess whether the patient is taking diuretics
- C. Obtain and attach defibrillator leads
- D. Assess the patient's last ejection fraction
Correct answer: Obtain and attach defibrillator leads
Rationale: In this scenario, the elevated Troponin T level indicates cardiac damage, possibly due to a myocardial infarction. A Troponin T value of 5.3 ng/mL is significantly elevated (normal levels are below 0.2 ng/mL), suggesting acute cardiac injury. Given the setting of an Emergency Room and the critical nature of the situation, the priority intervention should be to obtain and attach defibrillator leads. Elevated Troponin T levels can indicate a higher risk of arrhythmias, including ventricular fibrillation, which can lead to sudden cardiac arrest. Defibrillator leads are essential for monitoring the patient's cardiac rhythm and readiness for immediate defibrillation if necessary. Placing the patient in a 90-degree position (Choice A) or assessing diuretic use (Choice B) are not immediate priorities in this critical situation. Additionally, assessing the patient's last ejection fraction (Choice D) is important but not as urgent as preparing for potential life-threatening arrhythmias requiring defibrillation.
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