the home health nurse visits a male client to provide wound care and finds the client lethargic and confused his wife states he fell down the stairs t
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should

Correct answer: B

Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.

2. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Correct answer: C

Rationale: In the scenario of persistent vomiting, the child is at risk of developing metabolic alkalosis due to the loss of hydrochloric acid. Vomiting leads to the loss of gastric acid, resulting in an imbalance that causes metabolic alkalosis. Metabolic acidosis is incorrect as it would occur in a child with diarrhea due to the loss of bicarbonate. While diarrhea can sometimes be associated with vomiting, in this case, the primary focus is on the effects of vomiting. Hyperactive bowel sounds are not typically associated with vomiting, making this choice less relevant to the situation described.

3. To prepare a 56-year-old male patient with ascites for paracentesis, the nurse should?

Correct answer: C

Rationale: To prepare a patient with ascites for paracentesis, the nurse should ask the patient to empty the bladder. This is important to decrease the risk of bladder perforation during the procedure. The patient should be positioned in Fowler's position to facilitate the procedure, not lie flat in bed, which can compromise breathing. Placing the patient on NPO status is unnecessary as sedation is not typically required for paracentesis. Positioning the patient on the right side is not a standard preparatory measure for paracentesis.

4. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

Correct answer: A

Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.

5. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: A

Rationale: The correct answer is 'Respirations are 36 breaths/minute.' An increased respiratory rate is a crucial sign of respiratory distress in patients with COPD, necessitating immediate interventions like oxygen therapy or medications. The other options are common chronic changes seen in COPD patients. Option B, the 'Anterior-posterior chest ratio is 1:1,' is related to the barrel chest commonly seen in COPD due to hyperinflation. Option C, 'Lung expansion is decreased bilaterally,' is expected in COPD due to air trapping. Option D, 'Hyperresonance to percussion is present,' is typical in COPD patients with increased lung volume and air trapping.

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