NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The clinic nurse reviews the record of an infant and notes that the primary healthcare provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek healthcare for the infant?
- A. Diarrhea
- B. Projectile vomiting
- C. Regurgitation of feedings
- D. Foul-smelling, ribbon-like stools
Correct answer: Foul-smelling, ribbon-like stools
Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is a congenital anomaly characterized by an absence of ganglion cells in the rectum and other areas of the affected intestine. A key clinical manifestation of Hirschsprung's disease is chronic constipation that starts in the first month of life, leading to pellet-like or ribbon-like stools that have a foul smell. Another sign is the delayed passage or absence of meconium stool in the neonatal period. In addition to foul-smelling, ribbon-like stools, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive are also common clinical manifestations of this disorder. Options A, B, and C are not typically associated with Hirschsprung's disease, making them incorrect choices in this scenario.
2. When attempting to incorporate the Latino client's cultural background into the plan of care, which consideration is the most important?
- A. Socioeconomic considerations regarding hospitalization
- B. The meaning and attention the client places on the future
- C. The client's need to control care to ensure desired outcomes
- D. Inclusion of the family in the plan of care with the client's permission
Correct answer: Inclusion of the family in the plan of care with the client's permission
Rationale: The most important consideration when incorporating the Latino client's cultural background into the plan of care is the inclusion of the family in the care plan with the client's permission. In Latino cultures, family plays a vital role, and there is a strong emphasis on family support during challenging times. This support can positively impact the client's health outcomes and overall well-being. Socioeconomic status, although relevant, does not carry more weight than usual in healthcare decisions. Latino clients typically focus on the present rather than the future, and they often attribute outcomes to external factors like fate or divine intervention. While the client's need for control is important, involving the family aligns more closely with the cultural values and preferences of Latino clients.
3. Rales and rhonchi are frequently noted during an examination of lung sounds. What is the difference between the two?
- A. Rales are louder.
- B. Rhonchi are noted only in infants.
- C. Rales occur on inspiration, rhonchi on expiration.
- D. Rales are noted only in infants.
Correct answer: Rales occur on inspiration, rhonchi on expiration.
Rationale: The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract. Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi. Choice B is incorrect as rhonchi can be heard in individuals beyond infancy. Choice D is incorrect as rales can be present in patients of various age groups, not just infants.
4. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
Correct answer: Stage II
Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage. Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin. Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.
5. During the implementation phase of the nursing process when working with a hospitalized adult, which of the following actions would the nurse take?
- A. Formulate a nursing diagnosis of impaired gas exchange
- B. Record in the medical record the distance a client ambulates in the hall
- C. Write individualized nursing orders in the care plan
- D. Compare client responses to the desired outcomes for pain relief
Correct answer: Record in the medical record the distance a client ambulates in the hall
Rationale: During the implementation phase of the nursing process, the nurse is responsible for carrying out or delegating nursing interventions and documenting nursing activities and client responses in the medical records. Option A involves diagnosing, which is part of the nursing process's earlier phases. Option C pertains to planning, which precedes implementation. Option D relates to evaluation, which comes after the implementation phase.
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