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NCLEX RN Exam Review Answers
1. A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eye drop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse's best response?
- A. ''You should wait more than 1 minute between different medications.''
- B. ''Your routine is very good! Can you demonstrate it for me?''
- C. ''It is actually not the best practice to close your eyes after instilling eye drops.''
- D. ''You should actually be pressing your finger in the other corner of the eye.''
Correct answer: ''You should wait more than 1 minute between different medications.''
Rationale: It is recommended to wait 10-15 minutes between different eye drop medications to give them time to absorb and avoid one medication washing another one out. Choice A is the correct response as the patient should wait more than 1 minute between administering different eye drop medications. Choice B is incorrect as the routine described by the patient needs improvement. Choice C is inaccurate as closing the eyes after instilling eye drops is a best practice to ensure proper absorption. Choice D is incorrect as pressing the finger to the corner of the eye nearest the nose is the correct technique.
2. The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation to stimuli
- D. Emotional lability
Correct answer: Decrease in level of consciousness
Rationale: A decrease in the level of consciousness is a critical finding that would warrant immediate attention in a client post right cerebrovascular accident. This change may indicate an increase in intracranial pressure, leading to inadequate oxygenation of the brain. It could also reveal the presence of a transient ischemic attack, which may signal an impending thrombotic cerebrovascular accident. Loss of bladder control (choice B) can be managed and monitored but does not indicate an immediate threat to the client's life. Altered sensation to stimuli (choice C) can be a concerning finding but may not require immediate attention unless it affects the client's safety. Emotional lability (choice D) may be distressing for the client but does not pose an immediate risk to their health compared to a decrease in the level of consciousness.
3. A child is undergoing chemotherapy to treat a neuroblastoma, stage IV, and had his first chemotherapy session last week. He arrives with his mother for this week’s session. How would the nurse greet the child?
- A. How did you feel after your last treatment?
- B. What are your thoughts on the treatment so far?
- C. Did you experience any side effects after the last session?
- D. Are you ready for the next round of treatment?
Correct answer: How did you feel after your last treatment?
Rationale: The most appropriate way for the nurse to greet the child is by asking, 'How did you feel after your last treatment?' This question allows the child to share their experience voluntarily, empowering them to feel in control of the conversation. It also demonstrates empathy and a caring attitude. Option B, 'What are your thoughts on the treatment so far?' is broad and may not address the child's immediate feelings after the last session. Option C, 'Did you experience any side effects after the last session?' focuses solely on side effects and may predispose the child to think negatively. Option D, 'Are you ready for the next round of treatment?' does not address the child's current well-being or feelings, missing an opportunity for emotional support and connection.
4. Which of the following clients is most appropriate for receiving telemetry?
- A. A client with syncope potentially related to cardiac dysrhythmia
- B. A client with unstable angina
- C. A client with sinus rhythm and PVCs
- D. A client who had a myocardial infarction 6 hours ago
Correct answer: A client with syncope potentially related to cardiac dysrhythmia
Rationale: Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.
5. A urine pregnancy test:
- A. May be negative even if a blood pregnancy test is positive.
- B. Is positive only during the first trimester of pregnancy.
- C. Will be negative if the amount of LH isn't enough to meet or exceed the sensitivity of the testing device.
- D. All of the above.
Correct answer: May be negative even if a blood pregnancy test is positive.
Rationale: A urine pregnancy test detects HCG in a pregnant woman's urine. Blood levels of HCG are usually higher and register earlier than HCG levels in the urine. Choice A is correct because urine pregnancy tests may be negative even if a blood pregnancy test is positive due to the differences in HCG levels in blood and urine. Choice B is incorrect because a urine pregnancy test can be positive throughout pregnancy, not just in the first trimester. Choice C is incorrect because LH (luteinizing hormone) is not the hormone detected in a pregnancy test; it is HCG (human chorionic gonadotropin). Choice D is incorrect because not all the statements provided are true.
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