NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?
- A. Polyuria
- B. Weight gain
- C. Hypotension
- D. Grossly bloody urine
Correct answer: Weight gain
Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.
2. A nurse is assigned to care for a deaf client. During her lunch hour, she visits the hospital library and reads more about deaf culture in order to better provide appropriate care for her client. This action is an example of:
- A. Cultural knowledge
- B. Cultural noise
- C. Cultural diversity
- D. Cultural divide
Correct answer: Cultural knowledge
Rationale: Cultural knowledge involves seeking information and educating oneself about different cultural groups. In this scenario, the nurse is demonstrating cultural knowledge by learning more about deaf culture to improve the care provided to the deaf client. This proactive approach helps in understanding the client's background, beliefs, and communication preferences, leading to better outcomes. 'Cultural noise' and 'Cultural divide' are incorrect as they do not reflect the nurse's positive action of seeking knowledge to enhance care. 'Cultural diversity' is also incorrect as it does not accurately describe the nurse's specific action of acquiring knowledge about a particular culture.
3. After a mastectomy or a hysterectomy, a client may feel incomplete as a woman. Which statement would alert the nurse to this feeling in a client who has undergone a total hysterectomy?
- A. "I don’t know who can help me during my recovery."
- B. "I feel washed out; there isn’t much left."
- C. "I’m scared about the pain in recovery."
- D. "I can’t wait to get home; I so want to see my grandchild."
Correct answer: "I feel washed out; there isn’t much left."
Rationale: The correct answer is "I feel washed out; there isn’t much left." This statement suggests a feeling of emptiness or incompleteness after the surgical procedure. Concern about who can assist during recovery, fear of pain, or excitement to go home and see a grandchild are not indicative of feeling incomplete as a woman after a hysterectomy. These other statements focus on practical concerns, physical discomfort, and positive emotions, respectively.
4. Rales and rhonchi are frequently noted during an examination of lung sounds. What is the difference between the two?
- A. Rales are louder.
- B. Rhonchi are noted only in infants.
- C. Rales occur on inspiration, rhonchi on expiration.
- D. Rales are noted only in infants.
Correct answer: Rales occur on inspiration, rhonchi on expiration.
Rationale: The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract. Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi. Choice B is incorrect as rhonchi can be heard in individuals beyond infancy. Choice D is incorrect as rales can be present in patients of various age groups, not just infants.
5. When reading a lab report, you notice that a patient's sample is described as having anisocytosis. Which of the following most accurately describes the patient's condition?
- A. The patient has an abnormal condition of skin cells.
- B. The patient's red blood cells vary in size.
- C. The patient has a high level of fat cells and is obese.
- D. The patient's cells are indicative of necrosis.
Correct answer: The patient's red blood cells vary in size.
Rationale: Anisocytosis is a term that indicates variation in the size of red blood cells. When a patient is described as having anisocytosis, it means their red blood cells exhibit differences in size. This condition can be detected in blood samples and may indicate underlying blood disorders. The other choices are incorrect: Choice A refers to a skin cell condition, Choice C relates to obesity and fat cells, and Choice D suggests necrosis, none of which are associated with anisocytosis or red blood cell abnormalities. It is important to recognize specific terms like anisocytosis in laboratory reports to understand the potential implications for the patient's health.
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