NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. What preparation is necessary for a colposcopy procedure?
- A. NPO for 8-12 hours before the procedure.
- B. D/C all hypertension medications for two days prior to the procedure.
- C. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system.
- D. None of the above prep is necessary for this type of procedure.
Correct answer: D
Rationale: A colposcopy procedure is performed to examine the vagina and cervix. The only preparation required is washing the external genitals with soap and water on the morning of the procedure. Choices A, B, and C suggest unnecessary preparations that are not relevant to a colposcopy. NPO for 8-12 hours, discontinuing hypertension medications, and using laxatives are not part of the standard preparation for a colposcopy.
2. Which of the following tasks may be delegated to unlicensed assistive personnel?
- A. Cleansing a wound with peroxide
- B. Irrigating a colostomy
- C. Assisting with performing incentive spirometry
- D. Removing a saline-lock IV
Correct answer: C
Rationale: Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.
3. A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
- A. An adolescent male
- B. An elderly woman
- C. A young woman
- D. An elderly man
Correct answer: C
Rationale: The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.
4. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?
- A. Peaked T waves on the ECG
- B. Muscle spasms
- C. Constipation
- D. A prominent U wave on the ECG
Correct answer: A
Rationale: A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability. Muscle spasms (Choice B) are more commonly associated with hypocalcemia. Constipation (Choice C) is not a typical sign of hyperkalemia. A prominent U wave on the ECG (Choice D) is associated with hypokalemia, not hyperkalemia.
5. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?
- A. Hyponatremia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypercalcemia
Correct answer: D
Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.
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