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NCLEX RN Exam Review Answers
1. The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?
- A. Assess the patient for decreased level of consciousness
- B. Administer Normal Saline
- C. Insert an NG Tube
- D. Connect and read an EKG
Correct answer: Administer Normal Saline
Rationale: The patient is entering neurogenic shock due to the spinal cord injury, leading to hypotension and bradycardia. Administering Normal Saline is essential to replace fluid volume, which can help in treating the hypotension and bradycardia symptomatically. This intervention aims to stabilize the patient's cardiovascular status. Assessing for decreased level of consciousness (Choice A) may be important but addressing the hemodynamic instability takes precedence. Inserting an NG Tube (Choice C) and connecting and reading an EKG (Choice D) are not the immediate actions required for the presenting symptoms of hypotension and bradycardia.
2. After 5 years of unprotected intercourse, a childless couple comes to the fertility clinic. The husband tells the nurse that his parents have promised to make a down payment on a house for them if his wife gets pregnant this year. Which response would the nurse provide?
- A. ''This must be very difficult for you with this added pressure.''
- B. ''Having a child is a decision you should make without your parents’ input.''
- C. ''You’re lucky. It’s nice that your parents are making such a generous offer.''
- D. ''Five years without a pregnancy is a long time. You were right to come to the fertility clinic.''
Correct answer: ''This must be very difficult for you with this added pressure.''
Rationale: The correct response acknowledges the emotional challenge the couple is facing due to the added pressure of the incentive from the husband's parents. By expressing empathy and understanding, the nurse encourages the couple to open up about their feelings and concerns. Choice B is not the best response as it dismisses the husband's situation and fails to address the emotional impact of the added pressure. Choice C focuses on the parents' offer rather than the couple's emotional state, which is not the primary concern in this situation. Choice D, mentioning the duration of infertility, may come across as insensitive and may hinder open communication by potentially making the couple feel judged or discouraged.
3. The parents of an infant who underwent surgical repair of bladder exstrophy ask if the infant will be able to control their bladder as they get older. How should the nurse respond?
- A. Your child will need catheterization until bladder control is gained.
- B. Your child will be able to control their bladder like other children.
- C. You should potty train your child at the same time you normally would.
- D. Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Correct answer: Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Rationale: Bladder exstrophy is a congenital defect where the infant is born with the bladder located on the outside of the body. Surgical repair typically occurs within the first 1 to 2 days of life. In the following 3 to 5 years post-surgery, urine will drain freely from the urethra due to the absence of a sphincter mechanism. This period allows the bladder to develop capacity as the child grows. Subsequent surgical interventions will be required to establish a functioning sphincter mechanism. Therefore, the correct response is that the child will not have a sphincter mechanism for the first 3 to 5 years, leading to urine draining freely. Options A, B, and C are incorrect as they do not align with the physiological process and management of bladder exstrophy.
4. A patient underwent fiberoptic colonoscopy 18 hours ago and presents to the emergency department with increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
- A. Bowel perforation
- B. Viral gastroenteritis
- C. Colon cancer
- D. Diverticulitis
Correct answer: A: Bowel perforation
Rationale: The correct answer is bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy, with signs such as progressive abdominal pain, fever, chills, and tachycardia indicating advancing peritonitis. Although colonoscopic perforation is rare (0.03% to 0.7% incidence), it can lead to high mortality and morbidity rates. Viral gastroenteritis (Choice B) typically presents with symptoms like diarrhea, nausea, vomiting, and abdominal cramps, but it is not the most immediate concern in this scenario. Colon cancer (Choice C) and diverticulitis (Choice D) are important conditions but are less likely to present acutely after colonoscopy compared to bowel perforation.
5. Why is it important for the nurse to inform the family about the client's situation?
- A. To decrease the client's anxiety
- B. To help the family better adapt to necessary role changes
- C. To improve communication between family and nursing staff
- D. To ensure a more relaxed atmosphere for the client
Correct answer: To help the family better adapt to necessary role changes
Rationale: It is crucial for the nurse to inform the family about the client's situation to help them better adapt to necessary role changes. By providing early notification, the family can start preparing for potential adjustments. While reducing the client's anxiety and improving communication with the nursing staff are important, the primary purpose is to assist the family in undertaking the required role changes. Creating a relaxed atmosphere for the client, although beneficial, is not the main objective in this situation.
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