NCLEX-RN
NCLEX RN Exam Questions
1. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct answer: A
Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.
2. A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'
- A. Green vegetables and liver
- B. Yellow vegetables and red meat
- C. Carrots
- D. Milk
Correct answer: A
Rationale: Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.
3. You are responsible for reviewing the nursing unit's refrigerator. Which of the following drugs, if found inside the fridge, should be removed?
- A. Nadolol (Corgard)
- B. Opened (in-use) Humulin N injection
- C. Urokinase (Kinlytic)
- D. Epoetin alfa IV (Epogen)
Correct answer: A
Rationale: Nadolol (Corgard) should be removed if found inside the fridge because it is supposed to be stored at room temperature between 59 to 86 �F (15 and 30 �C) away from heat, moisture, and light. Storing it in the refrigerator can alter its effectiveness and stability. Option B, the opened Humulin N injection, should not be stored in the refrigerator as it is an in-use product and can remain at room temperature for a certain period as per manufacturer guidelines. Option C, Urokinase (Kinlytic), and Option D, Epoetin alfa IV (Epogen), do not require refrigeration and can be stored at room temperature. Therefore, Nadolol (Corgard) is the drug that should be removed from the fridge.
4. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
- A. Emergency pericardiocentesis
- B. Stabilization of the chest wall with tape
- C. Administration of an inhaled bronchodilator
- D. Insertion of a chest tube with a chest drainage system
Correct answer: D
Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
5. A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?
- A. Cracks in the corners of the mouth
- B. Peeling skin from the tongue and gums
- C. Increased dental caries
- D. Dry mouth
Correct answer: D
Rationale: Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.
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