NCLEX-RN
NCLEX RN Exam Review Answers
1. When assessing a patient being treated for Parkinson's Disease with classic symptoms, the nurse expects to note which assessment finding?
- A. Tremors
- B. Low Urine Output
- C. Exaggerated arm movements
- D. Risk for Falls
Correct answer: A
Rationale: When assessing a patient with Parkinson's Disease, the nurse should expect to note tremors as one of the cardinal signs of the condition. The classic symptoms of Parkinson's Disease include tremors, rigidity, bradykinesia (slow movements), and postural instability. Therefore, choices B, C, and D are incorrect. Low urine output is not a typical assessment finding associated with Parkinson's Disease. Exaggerated arm movements are not characteristic of the usual motor symptoms seen in Parkinson's Disease. While patients with Parkinson's Disease are at an increased risk for falls due to balance and coordination issues, 'Risk for Falls' is not an assessment finding but rather a potential nursing diagnosis based on the assessment findings.
2. Which of these individuals would the nurse suspect as having the greatest risk of contracting Hepatitis B?
- A. A sexually active 45-year-old man who has Type 1 Diabetes
- B. A 75-year-old woman who lives in a crowded nursing home
- C. A child who lives in a country with poor sanitation and hygiene standards
- D. A sexually active 23-year-old man who works in a hospital
Correct answer: D
Rationale: The correct answer is a sexually active 23-year-old man who works in a hospital. This individual is at the highest risk of contracting Hepatitis B due to exposure in a healthcare setting where potential bloodborne pathogens are present. Being sexually active also increases the risk of transmission through sexual contact. Choice A, a 45-year-old man with Type 1 Diabetes, is not directly associated with an increased risk of Hepatitis B. Choice B, a 75-year-old woman living in a crowded nursing home, is at risk for other infections due to the living environment but not specifically for Hepatitis B. Choice C, a child in a country with poor sanitation, is more at risk for water or foodborne illnesses rather than Hepatitis B transmission.
3. When teaching the client with tuberculosis about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct answer: A
Rationale: The nurse should emphasize the importance of monitoring liver function tests in clients taking INH due to the risk of hepatocellular injury and hepatitis associated with this medication. Regular assessment of liver enzymes can help detect liver damage early. Monitoring kidney function, blood sugar levels, or cardiac enzymes is not specifically required for clients taking INH and tuberculosis treatment.
4. The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?
- A. 14
- B. 16
- C. 17
- D. 28
Correct answer: B
Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. The nurse counted eight respirations over 30 seconds, so doubling this count gives a respiratory rate of 16 breaths per minute. This calculation is based on the assumption that the client's breathing pattern remained relatively stable during the two 30-second intervals. Options A, C, and D are incorrect because they do not reflect the accurate count obtained without interruptions. Choice B (16) is the correct answer as it reflects the uninterrupted count of respirations by the nurse.
5. A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct answer: D
Rationale: During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.
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