NCLEX-RN
NCLEX RN Exam Questions
1. While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?
- A. Melena
- B. Nausea
- C. Hernia
- D. Hyperthermia
Correct answer: A
Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (Choice B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (Choice C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (Choice D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.
2. During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.
- A. Proteinuria
- B. Weight gain
- C. Decreased serum lipids
- D. Hematuria
Correct answer: A
Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.
3. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?
- A. Cracks at the corners of the mouth
- B. Altered mental status
- C. Bleeding gums and loose teeth
- D. Anorexia and diarrhea
Correct answer: C
Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.
4. Which of the following medications taken by the patient is least likely to cause urine discoloration?
- A. Sulfasalazine
- B. Levodopa
- C. Phenolphthalein
- D. Aspirin
Correct answer: D
Rationale: The correct answer is Aspirin. Aspirin is not known to cause urine discoloration. Sulfasalazine is associated with causing orange-yellow discoloration of urine. Levodopa can cause darkening of urine to a brown or black color. Phenolphthalein has been linked to pink or red discoloration of urine. Therefore, among the options provided, Aspirin is the medication least likely to cause urine discoloration.
5. A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
- A. Assess the patient for nuchal rigidity
- B. Determine the patient's past exposure to infectious organisms
- C. Check the patient's WBC lab values
- D. Monitor for increased lethargy and drowsiness
Correct answer: D
Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.
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