NCLEX-RN
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: C
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. When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?
- A. Leukopenia.
- B. Hypokalemia.
- C. Polycythemia.
- D. Hypoglycemia.
Correct answer: B
Rationale: When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.
3. The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
- A. Is there any family history of TB?
- B. How long have you lived in the United States?
- C. Do you take any over-the-counter (OTC) medications?
- D. Have you received the bacille Calmette-Guerin (BCG) vaccine for TB?
Correct answer: D
Rationale: It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.
4. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?
- A. Catheterizing the infant using the smallest available Foley catheter
- B. Attaching a urinary collection device to the infant's perineum for collection
- C. Obtaining the specimen from the diaper by squeezing the diaper after the infant voids
- D. Noting the time of the next expected voiding and then preparing a specimen cup for the urine
Correct answer: B
Rationale: The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.
5. Which of the following glands found in the skin secretes a liquid called Sebum?
- A. Apocrine Glands
- B. Sebaceous Glands
- C. Lacrimal Glands
- D. Sweat Glands
Correct answer: B
Rationale: Sebum is a liquid secreted by glands in the skin known as sebaceous glands. Sebum's primary function is to lubricate the skin and help maintain its integrity. Apocrine glands secrete a different type of sweat that is odorless but can develop an odor when combined with bacteria on the skin. Lacrimal glands produce tears to keep the eyes moist, and sweat glands secrete sweat to regulate body temperature through evaporation. Therefore, the correct answer is Sebaceous Glands because they specifically secrete sebum, distinguishing them from the other gland types mentioned.
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