NCLEX NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. A client is suspected of having carbon monoxide poisoning. Which of the following symptoms are associated with this condition?
- A. Red rash across the trunk and extremities
- B. Nausea, vomiting, seizures
- C. Flushing of the face and neck
- D. Abdominal pain radiating to the back
Correct answer: Nausea, vomiting, seizures
Rationale: The correct answer is 'Nausea, vomiting, seizures.' Carbon monoxide poisoning can present with symptoms such as headache, dizziness, weakness, nausea, vomiting, and confusion. Severe cases can progress to seizures, coma, and even death. It is crucial for healthcare providers to recognize these symptoms promptly to initiate appropriate treatment. Choices A, C, and D are incorrect because a red rash, flushing of the face and neck, and abdominal pain radiating to the back are not typically associated with carbon monoxide poisoning. It is essential to be aware of the common manifestations of carbon monoxide poisoning to ensure timely intervention and prevent adverse outcomes.
2. When a blood pressure cuff is too wide for a client's arm, what type of reading might this blood pressure cuff produce?
- A. A normal reading
- B. An abnormally low reading
- C. An abnormally high reading
- D. A fluctuating reading
Correct answer: An abnormally low reading
Rationale: When a blood pressure cuff is too wide for a client's arm, it may produce an abnormally low blood pressure reading. This occurs because the oversized cuff can lead to an underestimation of blood pressure. It is essential to ensure that the cuff fits appropriately to obtain an accurate reading. An abnormally high reading (Choice C) is less likely with an oversized cuff, as it generally leads to lower readings. A normal reading (Choice A) is unlikely due to the inaccuracies caused by the oversized cuff. A fluctuating reading (Choice D) is not a typical result of using a cuff that is too wide; instead, it usually leads to consistently low readings.
3. A 9-year-old boy is told that he must stay in the hospital for at least 2 weeks. The nurse finds him crying and unwilling to talk. What is the priority nursing care at this time?
- A. Assuring him that his illness is not permanent
- B. Distracting him to prevent further embarrassment
- C. Arranging for him to receive tutoring immediately
- D. Providing privacy to allow him to express his feelings
Correct answer: Providing privacy to allow him to express his feelings
Rationale: The priority nursing care for a 9-year-old child who is crying and unwilling to talk in the hospital is to provide privacy to allow him to express his feelings. Children need an opportunity to express their emotions in private, and talking about their feelings can be therapeutic. Assurances about the illness not being permanent may not be the child's primary concern at this moment. Distracting the child could give the impression that crying is wrong. Arranging tutoring does not address the immediate emotional needs of the child.
4. Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?
- A. The test determines if the client is anemic and needs iron supplements
- B. The test determines if there is excess glucose building up in the urine
- C. The test determines the amount of hemoglobin reaching the liver to support gluconeogenesis
- D. The test determines the amount of hemoglobin that is coated with glucose
Correct answer: The test determines the amount of hemoglobin that is coated with glucose
Rationale: A hemoglobin A1C test, also known as a glycated hemoglobin test, determines the amount of hemoglobin that is coated with glucose. Excess glucose in the bloodstream may cause it to attach to hemoglobin on red blood cells. Because the life of these cells is between 2 and 3 months, the hemoglobin A1C is an accurate measurement of a client's glucose during that time. Choices A, B, and C are incorrect. Choice A relates to anemia and iron supplements, which are not assessed by a hemoglobin A1C test. Choice B mentions excess glucose in the urine, which is typically assessed through a urine glucose test, not the hemoglobin A1C test. Choice C is incorrect as the test is not related to the amount of hemoglobin reaching the liver to support gluconeogenesis; instead, it specifically measures the amount of hemoglobin that is glycated or coated with glucose.
5. The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care?
- A. Infection.
- B. Poor body image.
- C. Decreased urinary elimination.
- D. Cracking oral mucous membranes.
Correct answer: Infection.
Rationale: In a neonate with gastroschisis, the bowel herniates through a defect in the abdominal wall without a covering membrane, which puts the neonate at high risk of infection. Immediate surgical repair is necessary due to the vulnerability of the exposed bowel to infection. Therefore, the most critical concern for the nurse to address in the plan of care of a neonate with gastroschisis is preventing infection. Poor body image is not a priority in neonatal care as neonates do not have body image concerns. Decreased urinary elimination is not typically a direct consequence of gastroschisis as it primarily affects the gastrointestinal system, not the genitourinary system. Cracking oral mucous membranes are not relevant to gastroschisis as it involves the lower gastrointestinal system, not the oral cavity.
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