NCLEX-RN
NCLEX RN Exam Review Answers
1. A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not expect to be prescribed for this condition?
- A. Acyclovir (Zovirax)
- B. Mannitol (Osmitrol)
- C. Lactated Ringer's
- D. Phenytoin (Dilantin)
Correct answer: C
Rationale: In the treatment of encephalitis, medications like Acyclovir and Phenytoin are commonly prescribed. Acyclovir is an antiviral medication used to treat viral infections like herpes simplex virus, which can cause encephalitis. Phenytoin is an antiepileptic drug that may be used to manage seizures associated with encephalitis. Mannitol is a diuretic used to reduce intracranial pressure (ICP) by decreasing cerebral edema. Lactated Ringer's solution, on the other hand, is primarily used in fluid replacement therapy and may not be indicated if a patient is at risk for high ICP, as excessive fluid administration could worsen cerebral edema and increase ICP.
2. During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
- A. "I have constant blurred vision."?
- B. "I can't see on my left side."?
- C. "I have to turn my head to see my room."?
- D. "I have specks floating in my eyes."?
Correct answer: C
Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.
3. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is:
- A. Surgical repair of a diseased coronary artery
- B. Placement of an automatic internal cardiac defibrillator
- C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
- D. Non-invasive radiographic examination of the heart
Correct answer: C
Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow. It is performed during a cardiac catheterization to improve coronary artery blood flow in a diseased artery. Surgical repair of a diseased coronary artery is typically done through procedures like aorto-coronary bypass graft (ACBG) rather than PTCA. Placement of an automatic internal cardiac defibrillator (AICD) is a different procedure used for managing cardiac arrhythmias. Non-invasive radiographic examination of the heart refers to procedures like echocardiography or cardiac MRI, not PTCA.
4. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse should?
- A. place the patient on NPO status.
- B. assist the patient to lie flat in bed.
- C. ask the patient to empty the bladder.
- D. position the patient on the right side.
Correct answer: C
Rationale: To prepare a patient with ascites for paracentesis, the nurse should ask the patient to empty the bladder. This is important to decrease the risk of bladder perforation during the procedure. The patient should be positioned in Fowler's position to facilitate the procedure, not lie flat in bed, which can compromise breathing. Placing the patient on NPO status is unnecessary as sedation is not typically required for paracentesis. Positioning the patient on the right side is not a standard preparatory measure for paracentesis.
5. A client presents with symptoms of a sore throat, swollen lymph nodes in the neck, fever, chills, and extreme fatigue. Based on these symptoms, which of the following illnesses could the nurse consider for this client?
- A. Methicillin-resistant Staphylococcus aureus (MRSA)
- B. Hepatitis B
- C. Infectious mononucleosis
- D. Norovirus infection
Correct answer: C
Rationale: Infectious mononucleosis is a viral disease caused by the Epstein-Barr virus. The symptoms of sore throat, fever, chills, swollen lymph nodes, and extreme fatigue are characteristic of infectious mononucleosis. The diagnosis is confirmed through the client's history and blood tests for the Epstein-Barr virus. Methicillin-resistant Staphylococcus aureus (MRSA) presents with localized skin infections, not the systemic symptoms described. Hepatitis B typically presents with jaundice, abdominal pain, and liver inflammation, not the symptoms described. Norovirus infection commonly causes gastrointestinal symptoms like vomiting and diarrhea, not the symptoms presented by the client.
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