NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
- A. We will encourage our child to cough every few hours on a daily basis.
- B. We will make sure that our child participates in physical activity every day.
- C. We will provide comfort measures to reduce any crying periods by our child.
- D. We will be sure to give our child a Fleet enema every day to prevent constipation.
Correct answer: C
Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
2. What should the nurse in the emergency department do first for a new patient who is vomiting blood?
- A. Insert a large-gauge IV catheter.
- B. Draw blood for coagulation studies.
- C. Check blood pressure (BP), heart rate, and respirations.
- D. Place the patient in the supine position.
Correct answer: C
Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.
3. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.
4. To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
- A. bilirubin levels.
- B. ammonia levels.
- C. potassium levels.
- D. prothrombin time.
Correct answer: B
Rationale: In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.
5. The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
- A. Offer psychological support for depression.
- B. Offer high-calorie, high-protein dietary choices.
- C. Administer prescribed opioids to relieve pain as needed.
- D. Teach about the need to avoid scratching any pruritic areas.
Correct answer: C
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
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