NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. When teaching the client with tuberculosis about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct answer: A
Rationale: The nurse should emphasize the importance of monitoring liver function tests in clients taking INH due to the risk of hepatocellular injury and hepatitis associated with this medication. Regular assessment of liver enzymes can help detect liver damage early. Monitoring kidney function, blood sugar levels, or cardiac enzymes is not specifically required for clients taking INH and tuberculosis treatment.
2. Which of the following patients is at the greatest risk for a stroke?
- A. A 60-year-old male who weighs 270 pounds, has atrial fibrillation, and has had a TIA in the past
- B. A 75-year-old male who has frequent migraines, drinks a glass of wine every day, and is Hispanic
- C. A 40-year-old female who has high cholesterol and uses oral contraceptives
- D. A 65-year-old female who is African American, has sickle cell disease, and smokes cigarettes
Correct answer: A
Rationale: The correct answer is the 60-year-old male who has a combination of significant risk factors for stroke, including atrial fibrillation, a history of a transient ischemic attack (TIA), and obesity. These factors greatly increase his risk of stroke. While other choices may have some individual risk factors, they do not collectively pose as high a risk as the patient described in option A. Option B includes migraines and alcohol consumption but lacks other major risk factors seen in option A. Option C mentions high cholesterol and oral contraceptives, which are risk factors but not as significant as atrial fibrillation and a prior TIA. Option D includes smoking and sickle cell disease but lacks the crucial risk factors present in option A.
3. A patient with stage I nonsmall cell lung cancer expresses a preference for chemotherapy over surgery. Which response by the nurse is most appropriate?
- A. Are you concerned about the potential pain from surgery?
- B. Have you had negative experiences with previous surgeries?
- C. Surgery is the recommended treatment for stage I lung cancer.
- D. Tell me about your understanding of the different available treatments.
Correct answer: D
Rationale: The most appropriate response by the nurse in this situation is to gather more information about the patient's concerns and preferences. By asking the patient to share their understanding of the available treatments, the nurse encourages open communication and gains insight into the patient's knowledge and preferences. Option A focuses solely on pain, which may not be the patient's primary concern. Option B assumes negative experiences without exploring the patient's current thoughts. Option C, stating that surgery is the recommended treatment, dismisses the patient's preference and does not address their concerns. Chemotherapy is not the primary treatment for nonsmall cell lung cancer; it may be used for nonresectable tumors or as adjuvant therapy to surgery, making it crucial for the nurse to explore the patient's treatment preferences and understanding.
4. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs.
- B. Massage the fundus.
- C. Offer a bedpan.
- D. Check for perineal lacerations.
Correct answer: B
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
5. A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn't able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient's symptoms?
- A. Anesthesia reaction
- B. Hyperglycemia
- C. Hypoglycemia
- D. Diabetic ketoacidosis
Correct answer: C
Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.
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