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NCLEX RN Exam Review Answers
1. The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?
- A. Severe and persistent diarrhea
- B. Intense pain in the toe
- C. Yellow-tinged sclera
- D. Headache
Correct answer: Yellow-tinged sclera
Rationale: In patients with sickle cell disease, severe generalized pain can be associated with vaso-occlusive crises, but yellow-tinged sclera is a common clinical finding related to sickle cell disease. This yellowing of the sclera, known as jaundice, occurs due to the release of bilirubin from damaged or destroyed red blood cells. Severe and persistent diarrhea is not a typical assessment finding in sickle cell disease. Intense pain in the toe may be associated with vaso-occlusive crisis but is not the expected assessment finding in this scenario. Headache is a common symptom in many conditions but is not specifically related to the assessment finding expected in a patient with sickle cell disease presenting with severe generalized pain.
2. In which of the following conditions would a healthcare provider not administer erythromycin?
- A. Campylobacteriosis infection
- B. Legionnaires disease
- C. Pneumonia
- D. Multiple Sclerosis
Correct answer: Multiple Sclerosis
Rationale: Erythromycin is an antibiotic used to treat bacterial infections. Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system, involving the brain and spinal cord. Since MS is not caused by bacteria, administering erythromycin would not be appropriate. Campylobacteriosis infection, Legionnaires disease, and pneumonia are bacterial infections that can be treated with erythromycin, making them incorrect choices for conditions where erythromycin would not be administered.
3. The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
- A. The oxygen saturation is 94%.
- B. The blood pressure is 98/56 mm Hg.
- C. The patient's central IV line is disconnected.
- D. The international normalized ratio (INR) is prolonged.
Correct answer: The patient's central IV line is disconnected.
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
4. A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?
- A. The client has an incontinent ostomy
- B. The client has an irregular bowel routine
- C. The client has diverticulitis
- D. The colostomy bag contains fecal material
Correct answer: The client has diverticulitis
Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.
5. Which of the following is an example of whistle-blowing?
- A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip
- B. A client sues a nurse because she failed to call the physician about his wound infection
- C. A nursing assistant calls for help when a client falls out of bed
- D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours
Correct answer: A nurse contacts administration about a colleague who takes supplies to use for a mission trip
Rationale: Whistle-blowing involves notifying administration or a supervisor about unethical or illegal activities. In this scenario, the nurse reporting a colleague taking supplies for personal use is an example of whistle-blowing as it involves reporting behavior that is dishonest and potentially harmful. Choices B, C, and D do not represent whistle-blowing. Choice B involves a legal action by a client against a nurse, choice C is a situation where immediate care is provided, and choice D is a case of neglect that should have been prevented.
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