NCLEX-RN
NCLEX RN Exam Questions
1. The healthcare professional in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the healthcare professional finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
- A. Start a large-bore IV in the patient's arm
- B. Ask the patient for a stool sample
- C. Prepare to insert an NG Tube
- D. Administer intramuscular morphine sulfate as ordered
Correct answer: A
Rationale: The priority intervention in this scenario is to start a large-bore IV in the patient's arm. The patient's low blood pressure (95/60) and elevated pulse rate (110 beats per minute) indicate a potential hemorrhage, requiring immediate fluid resuscitation. Starting a large-bore IV will allow for rapid administration of fluids to stabilize the patient's condition. Asking for a stool sample, preparing to insert an NG tube, or administering morphine sulfate should not take precedence over addressing the hemodynamic instability and potential hemorrhage observed in the patient. These actions may be considered later in the patient's care, but the primary focus should be on addressing the critical issue of fluid replacement and stabilization.
2. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?
- A. Place a tourniquet at the level of the elbow
- B. Apply direct pressure to the injury
- C. Administer a bolus of 0.9% Normal Saline
- D. Elevate the injured extremity on a pillow
Correct answer: B
Rationale: The correct first action for the nurse in this scenario is to apply direct pressure to the injury. When a client presents with traumatic hand amputation causing excessive bleeding, the immediate goal is to control the bleeding. Applying direct pressure with a sterile dressing helps to stem the flow of blood and stabilize the patient. Placing a tourniquet at the level of the elbow should be avoided initially as it may lead to further complications such as tissue damage. Administering a bolus of 0.9% Normal Saline is not the priority in this situation where hemorrhage control is crucial. Elevating the injured extremity on a pillow does not address the primary concern of controlling the bleeding and stabilizing the patient.
3. You are caring for Thomas N., a 77-year-old man with edema in his legs and a fluid restriction. You have been assigned to weigh him daily. Based on these symptoms and the care he is receiving, what disorder is he most likely affected by?
- A. Diabetes
- B. Dementia
- C. Congestive heart failure
- D. Contiguous heart disease
Correct answer: C
Rationale: Thomas N.'s symptoms of edema in his legs and fluid restriction point towards congestive heart failure (CHF) rather than dementia or diabetes. In CHF, patients often present with dependent edema in their legs due to excessive blood volume, leading to fluid intake restrictions and a low-salt diet. Daily weight monitoring is crucial in CHF to assess fluid retention or loss. Diabetes primarily affects blood sugar levels, dementia is a cognitive disorder, and 'Contiguous heart disease' is not a recognized medical term, making choices A, B, and D incorrect in this scenario.
4. The nurse is reviewing the characteristics of culture. Which statement is correct regarding the development of one's culture?
- A. Learned through language acquisition and socialization.
- B. Genetically determined on the basis of racial background.
- C. A nonspecific phenomenon and is adaptive but unnecessary.
- D. Biologically determined on the basis of physical characteristics.
Correct answer: A
Rationale: Culture is a complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values learned from birth through the processes of language acquisition and socialization. It is not biologically or genetically determined, but rather acquired through social interactions. The correct answer, 'Learned through language acquisition and socialization,' aligns with the understanding that culture is a learned behavior. Choices B, C, and D are incorrect because culture is not genetically determined, nonspecific, or biologically based on physical characteristics. Understanding that culture is acquired through language and socialization is essential for healthcare providers to provide culturally competent care.
5. Rhogam is most often used to treat____ mothers that have a ____ infant.
- A. RH positive, RH positive
- B. RH positive, RH negative
- C. RH negative, RH positive
- D. RH negative, RH negative
Correct answer: C
Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system. Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive. Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive. Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.
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