NCLEX-RN
NCLEX RN Exam Review Answers
1. The client is receiving an MAOI. Which foods should the nurse caution the client to avoid?
- A. Pork, spinach, and fresh oysters
- B. Milk, grapes, and meat tenderizers
- C. Cheese, beer, and products with chocolate
- D. Leafy green vegetables, fresh apples, and ice cream
Correct answer: C: Cheese, beer, and products with chocolate
Rationale: The correct answer is C. When a client is receiving a monoamine oxidase inhibitor (MAOI), they should avoid foods high in tyramine to prevent a hypertensive crisis. Cheese, beer, and products with chocolate are rich in tyramine and can interact with MAOIs, leading to a dangerous rise in blood pressure. Choices A, B, and D do not contain high levels of tyramine and are not typically restricted when taking MAOIs.
2. Which example best describes the concept of beneficence?
- A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
- B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
- C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
- D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented
Correct answer: A nurse provides pain medication for a client in the recovery room who is experiencing pain
Rationale: Beneficence is the ethical principle of doing good and acting in the best interest of the client. Providing pain relief to a client in the recovery room who is experiencing pain aligns with beneficence as it promotes the client's well-being and comfort. Choice B is related to autonomy, where the client's wishes regarding treatment are respected. Choice C involves confidentiality and the client's right to privacy. Choice D represents nonmaleficence, as withholding pain medication from a client in pain could cause harm and goes against the principle of doing no harm.
3. What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct answer: 7/7/2017
Rationale: The expected date of delivery is calculated using Nagle’s rule which is: The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery
4. A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
- A. Knowledge Deficit related to post-partum blood loss
- B. Self-Care Deficit related to post-partum neglect
- C. Fluid Volume Deficit related to post-partum hemorrhage
- D. Body Image Disturbance related to body changes after delivery
Correct answer: C: Fluid Volume Deficit related to post-partum hemorrhage
Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.
5. You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:
- A. PT referral for development of a planned exercise program
- B. Avoidance of prolonged sun exposure
- C. Hot baths to promote muscle relaxation
- D. Instructions to evaluate the home environment to ensure safety
Correct answer: Hot baths to promote muscle relaxation
Rationale: Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.
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