NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?
- A. Restrict fluids as prescribed.
- B. Care for the arteriovenous fistula.
- C. Encourage foods high in potassium.
- D. Administer analgesics as prescribed.
Correct answer: Restrict fluids as prescribed.
Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.
2. Intermittent fevers are:
- A. fevers which come and go.
- B. fevers which rise and fall but are always considered above the patient's average temperature.
- C. fevers which fluctuate more than three degrees and never return to normal.
- D. None of the above.
Correct answer: fevers which come and go.
Rationale: Intermittent fevers are characterized by periods of fever followed by periods of normal body temperature. They alternate between being febrile and afebrile. Continuous fevers show minimal fluctuations over a 24-hour period, while remittent fevers fluctuate significantly but do return to normal body temperature. Choice A is correct as it accurately describes intermittent fevers. Choices B and C are incorrect as they do not fully capture the defining characteristic of intermittent fevers, which involve cyclical episodes of fever and normal temperature. Choice D is incorrect as there is a specific definition for intermittent fevers.
3. 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
- A. Place a call to the client’s healthcare provider for instructions
- B. Send him to the emergency room for evaluation
- C. Reassure the client’s wife that the symptoms are transient
- D. Instruct the client’s wife to call the doctor if his symptoms become worse
Correct answer: Send him to the emergency room for evaluation
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.
4. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
- A. Stop the interview at this point and resume later when the client is better able to concentrate
- B. Ask the client, 'Are you seeing something on the ceiling?'
- C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
- D. Continue the interview without commenting on the client’s behavior
Correct answer: Ask the client, 'Are you seeing something on the ceiling?'
Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.
5. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?
- A. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
- B. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
- C. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
- D. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
Correct answer: pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
Rationale: The correct answer is D: pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%. These ABG results indicate uncompensated respiratory acidosis, a critical condition that requires immediate attention. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to a decrease in pH. The other options present normal or near-normal ABG values, indicating adequate oxygenation and ventilation. Therefore, these values would not be as urgent to report compared to the patient with respiratory acidosis in option D.
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