NCLEX NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
- A. Institute seizure precautions
- B. Weigh the child twice per shift
- C. Encourage the child to eat protein-rich foods
- D. Relieve boredom through physical activity
Correct answer: Institute seizure precautions
Rationale: Institute seizure precautions. The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications, and anticipatory preparation such as seizure precautions is needed. Weighing the child twice per shift may be necessary for monitoring fluid balance but is not specifically related to the complications of AGN. Encouraging the child to eat protein-rich foods is important for overall nutrition but does not directly address the potential complications of AGN. Relieving boredom through physical activity is beneficial for overall well-being but is not the priority in this situation where seizure precautions are essential.
2. Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
- A. Increase activity level.
- B. Maintain adequate nutrition
- C. Establish a stable environment
- D. Identify sources of hepatitis exposure
Correct answer: Maintain adequate nutrition
Rationale: The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.
3. While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
- A. Electrocardiogram
- B. Bell of the stethoscope
- C. Diaphragm of the stethoscope
- D. Palpation with the nurse’s palm of the hand
Correct answer: Bell of the stethoscope
Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse’s palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.
4. A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?
- A. Immobilize the cervical area to prevent further injury
- B. Monitor the patient's level of consciousness to prevent neurologic deterioration
- C. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
- D. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Correct answer: Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Rationale: The correct answer is to facilitate tissue perfusion to the spinal cord while maintaining airway and breathing. In the acute phase of a spinal cord injury, ensuring proper tissue perfusion to the spinal cord is crucial to prevent further damage. Maintaining airway, breathing, and circulation is essential in guiding the overall care for a patient with a spinal cord injury. Choices A, B, and C, while important in certain aspects of care, are not the overarching principles that guide the immediate management of a suspected spinal cord injury.
5. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
- A. Assist the client in using the bathroom one hour after going to bed
- B. Give the client a massage before bedtime
- C. Tuck bed sheets and blankets tightly around the client once settled in bed
- D. Give the client a pair of socks to wear if their feet become cold
Correct answer: Give the client a pair of socks to wear if their feet become cold
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
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