NCLEX NCLEX-RN
NCLEX RN Predictor Exam
1. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.
- A. Hopelessness
- B. Powerlessness
- C. Interrupted sleep pattern
- D. Disturbed self-esteem
Correct answer: A: Hopelessness, B: Powerlessness
Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.
2. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
- A. Record the amount on the client's fluid output record.
- B. Encourage the client to increase oral fluid intake.
- C. Notify the healthcare provider of the findings.
- D. Palpate the client's bladder for distention.
Correct answer: Record the amount on the client's fluid output record.
Rationale: The correct action for the nurse to take next is to record the amount of urine output on the client's fluid output record. The urine color and volume are within normal limits, indicating adequate hydration. There is no indication of a need to encourage increased oral fluid intake or notify the healthcare provider as the findings are normal. Palpating the client's bladder for distention is unnecessary in this scenario since the client has successfully voided a normal amount of urine after 4 hours.
3. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?
- A. Hyponatremia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypercalcemia
Correct answer: Hypercalcemia
Rationale: The parathyroid glands regulate calcium, vitamin D, and phosphorus in the body. Hyperparathyroidism leads to excessive production of parathyroid hormone, causing the release of calcium from bones into the bloodstream, resulting in elevated blood calcium levels, known as hypercalcemia. This puts individuals at risk of developing complications such as kidney stones, bone pain, osteoporosis, and neuropsychiatric symptoms. The other options, hyponatremia, hypocalcemia, and hypermagnesemia, are not directly associated with hyperparathyroidism. Hyponatremia is low sodium levels in the blood, hypocalcemia is low calcium levels, and hypermagnesemia is high magnesium levels, which are not typically seen in hyperparathyroidism.
4. A client in the ICU has been intubated and placed on a ventilator. The physician orders synchronous intermittent mandatory ventilation (SIMV). Which statement best describes the work of this mode of ventilation?
- A. The ventilator delivers a set rate and tidal volume regardless of whether the client is attempting to breathe
- B. The ventilator coordinates delivered breaths with the client's respiratory efforts
- C. The ventilator provides a supplemental breath for every third breath of the client
- D. The ventilator provides breaths during the expiratory phase of the client's respirations
Correct answer: The ventilator coordinates delivered breaths with the client's respiratory efforts
Rationale: Synchronous intermittent mandatory ventilation (SIMV) is a ventilation mode that coordinates delivered breaths with the client's own respiratory efforts. This mode allows the client to initiate breaths, with the ventilator providing preset breaths at a controlled rate and volume. Option A is incorrect because in SIMV, the ventilator syncs with the client's respiratory efforts. Option C is incorrect as it does not accurately depict the way SIMV works. Option D is also incorrect as SIMV does not specifically provide breaths during the expiratory phase of the client's respirations. Therefore, the correct answer is B, where the ventilator coordinates breath delivery with the client's breathing efforts.
5. A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct answer: Assist with active range of motion (ROM).
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
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