NCLEX-RN
NCLEX RN Exam Review Answers
1. A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
- A. Heparin will dissolve clots that you have.
- B. Heparin will reduce the platelets that make your blood clot.
- C. Heparin will work better than warfarin.
- D. Heparin will prevent new clots from developing.
Correct answer: D
Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.
2. When administering a shot of Vitamin K to a 30-day-old infant, which of the following target areas is the most appropriate?
- A. Gluteus maximus
- B. Gluteus minimus
- C. Vastus lateralis
- D. Vastus medialis
Correct answer: C
Rationale: When administering medications to infants, it is common to use the vastus lateralis muscle in the thigh for injections. The preferred site is the junction of the upper and middle thirds of the vastus lateralis muscle. This area provides a good muscle mass for the injection and minimizes the risk of hitting nerves or blood vessels. The gluteus maximus and gluteus minimus are not typically used for infant injections due to the risk of injury to the sciatic nerve. The vastus medialis is not as commonly used as the vastus lateralis for infant injections.
3. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?
- A. Call for a cardiac evaluation and implement appropriate measures
- B. Check the patient's oxygen saturation
- C. Inform the physician about the elevated BNP level
- D. Encourage the patient to limit physical activity
Correct answer: B
Rationale: An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.
4. Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
- A. Age
- B. Blood pressure
- C. Respiratory rate
- D. Oxygen saturation
Correct answer: D
Rationale: The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.
5. Which of the following glands found in the skin secretes a liquid called Sebum?
- A. Apocrine Glands
- B. Sebaceous Glands
- C. Lacrimal Glands
- D. Sweat Glands
Correct answer: B
Rationale: Sebum is a liquid secreted by glands in the skin known as sebaceous glands. Sebum's primary function is to lubricate the skin and help maintain its integrity. Apocrine glands secrete a different type of sweat that is odorless but can develop an odor when combined with bacteria on the skin. Lacrimal glands produce tears to keep the eyes moist, and sweat glands secrete sweat to regulate body temperature through evaporation. Therefore, the correct answer is Sebaceous Glands because they specifically secrete sebum, distinguishing them from the other gland types mentioned.
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