NCLEX-RN
NCLEX RN Exam Review Answers
1. The healthcare provider assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
- A. Audible crackles and orthopnea
- B. An audible wheeze and use of accessory muscles
- C. Audible crackles and use of accessory muscles
- D. Audible wheeze and orthopnea
Correct answer: B
Rationale: Choice B, 'An audible wheeze and use of accessory muscles,' is the correct answer. In asthma, patients commonly present with wheezing due to airway constriction and the use of accessory muscles to aid in breathing. Audible crackles (rales) are more commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis. Orthopnea, which is difficulty breathing while lying flat, is typically seen in conditions like heart failure or chronic obstructive pulmonary disease, rather than asthma. Choice C is incorrect as crackles are not a typical finding in asthma. Choice D is incorrect as orthopnea is not a common clinical manifestation of asthma.
2. A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?
- A. It is an acute bowel obstruction.
- B. It is a condition that causes an acute inflammatory process in the bowel.
- C. It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel.
- D. It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel.
Correct answer: D
Rationale: Intussusception is a condition in which a proximal segment of the bowel telescopes or prolapses into a distal segment of the bowel. This leads to bowel obstruction and potential ischemia. It is not an acute bowel obstruction, as the obstruction is caused by the telescoping of bowel segments rather than a blockage in the bowel lumen. Intussusception is not primarily an inflammatory process; instead, it is a mechanical issue involving bowel invagination. Choice A is incorrect as it does not accurately describe the pathophysiology of intussusception. Choice C is incorrect because it presents the opposite scenario of what happens in intussusception.
3. During an intake screening for a patient with hypertension who has been taking ramipril for 4 weeks, which statement made by the patient would be most important for the nurse to pass on to the physician?
- A. ''I get dizzy when I get out of bed.''
- B. ''I'm urinating much more than I used to.''
- C. ''I've been running on the treadmill for 10 minutes each day.''
- D. ''I can't get rid of this cough.''
Correct answer: D
Rationale: The correct answer is ''I can't get rid of this cough.'' Ramipril, an ACE inhibitor, commonly causes a persistent, dry cough as an adverse effect. This symptom can be indicative of bradykinin accumulation caused by ACE inhibitors. It is important for the nurse to inform the physician about this side effect so that a medication change to another class of antihypertensives, such as an ARB, may be considered. Choices A, B, and C are not directly related to the common adverse effects of ramipril and are not as concerning for a patient on this medication.
4. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?
- A. Bile-stained fecal emesis
- B. The passage of currant jelly-like stools
- C. Failure to pass meconium stool in the first 24 hours after birth
- D. Sausage-shaped mass palpated in the upper right abdominal quadrant
Correct answer: C
Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. Failure to pass meconium stool within the first 24 hours after birth is a key clinical manifestation associated with this disorder. This finding should prompt further assessment to confirm the suspected diagnosis. Other assessment findings in imperforate anus may include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options A, B, and D describe findings typically noted in intussusception, a different condition characterized by bowel obstruction and telescoping of the intestines that can present with bile-stained fecal emesis, the passage of currant jelly-like stools, and a sausage-shaped mass palpated in the upper right abdominal quadrant.
5. Which of the following clients is most appropriate for receiving telemetry?
- A. A client with syncope potentially related to cardiac dysrhythmia
- B. A client with unstable angina
- C. A client with sinus rhythm and PVCs
- D. A client who had a myocardial infarction 6 hours ago
Correct answer: A
Rationale: Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.
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