NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. How does shock typically progress?
- A. Compensated to hypotensive shock in hours and hypotensive shock to cardiac arrest in minutes
- B. Compensated to hypotensive shock in minutes and hypotensive shock to cardiac arrest in hours
- C. Hypotensive to compensated shock in hours and compensated shock to cardiac arrest in minutes
- D. Hypotensive to compensated shock in minutes and compensated shock to cardiac arrest in hours
Correct answer: Compensated to hypotensive shock in hours and hypotensive shock to cardiac arrest in minutes
Rationale: Shock typically progresses from a compensated state to hypotensive shock over a period of hours. In the compensated phase, the body is trying to maintain perfusion. It is crucial to identify and intervene during this phase to prevent progression to hypotensive shock, where blood pressure drops significantly. If not promptly managed, hypotensive shock can rapidly deteriorate into cardiac arrest in minutes due to inadequate perfusion to vital organs. Choices B, C, and D are incorrect as they do not follow the typical progression of shock stages as seen in clinical practice. Understanding the stages of shock and their timeframes is crucial for early recognition and appropriate intervention to prevent further deterioration.
2. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states, “My blood pressure is usually much lower.” The nurse should tell the client to:
- A. Go get a blood pressure check within the next 15 minutes
- B. Check blood pressure again in two (2) months
- C. See the healthcare provider immediately
- D. Visit the healthcare provider within one (1) week for a BP check
Correct answer: Go get a blood pressure check within the next 15 minutes
Rationale: The blood pressure reading of 160/96 mmHg is moderately high, indicating hypertension. Given that the client mentions their blood pressure is usually lower, there is concern for acute complications like a stroke. Therefore, an immediate reassessment of the blood pressure within the next 15 minutes is warranted to confirm the reading and take appropriate actions if necessary. Waiting for two months (Choice B) or a week (Choice D) could pose risks of delaying intervention. Seeing the healthcare provider immediately (Choice C) is a good option, but in this case, the urgency is not as high as to require immediate attention at the healthcare provider's office.
3. 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.
4. The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
- A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
- B. Obtain a thorough history and physical assessment from the patient’s family member.
- C. Immediately perform a complete history and physical assessment to obtain baseline information.
- D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Correct answer: Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Rationale: When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
5. A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Check the food diary
- D. Observe for signs of bleeding
Correct answer: Observe for signs of bleeding
Rationale: The priority concern for a client receiving thrombolytic medication, such as tissue plasminogen activator (alteplase), is to monitor for signs of bleeding. Thrombolytics work by converting plasminogen to plasmin, which degrades fibrin. This process can lead to the breakdown of both fibrin-bound plasminogen on thrombi surfaces and unbound plasminogen in the plasma. The resulting plasmin can degrade fibrin, fibrinogen, factor V, and factor VIII. Observing for signs of bleeding is crucial due to the increased risk of hemorrhage associated with thrombolytic therapy. Monitoring for neurological changes, signs of renal failure, or checking the food diary are not the immediate priorities compared to detecting and managing potential bleeding complications.
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