NCLEX NCLEX-RN
NCLEX RN Exam Review Answers
1. The parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism are provided with discharge instructions by the nurse. Which statement by the parents indicates the need for further instruction?
- A. I'll check his temperature.
- B. I'll give him medication so he'll be comfortable.
- C. I'll check his voiding to be sure there's no problem.
- D. I'll let him decide when to return to his play activities.
Correct answer: I'll let him decide when to return to his play activities.
Rationale: Cryptorchidism is a condition where one or both testes fail to descend into the scrotal sac. Orchiopexy, a surgical correction, may be required. After surgery, it is crucial to restrict vigorous activities for 2 weeks to promote healing and prevent injury. Allowing the child to decide when to return to play activities may lead to delayed healing and increased risk of injury, as 2-year-olds typically want to be active. Checking the child's temperature, administering analgesics as needed, and monitoring urine output are important postoperative care measures to ensure recovery and detect complications early. Therefore, the statement indicating the need for further instruction is the one related to letting the child decide when to resume play activities.
2. A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?
- A. I'm feeling extremely thirsty and will get some water after this.
- B. I can feel my heart racing.
- C. My shoulder and arm are hurting.
- D. My blood pressure reading is 158/80
Correct answer: C: My shoulder and arm are hurting.
Rationale: The correct answer is 'C: My shoulder and arm are hurting.' Unilateral arm and shoulder pain are classic symptoms of myocardial ischemia, indicating possible heart issues. In this scenario, immediate intervention is required, and the stress test should be halted. Choice A about feeling thirsty does not indicate an acute medical issue. Choice B mentioning heart racing is expected during a stress test. Choice D, a blood pressure reading of 158/80, while slightly elevated, does not present an immediate concern compared to the symptoms of arm and shoulder pain suggesting cardiac distress.
3. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around their neck. Which action by the nurse is appropriate?
- A. Ask the patient about the item and its significance.
- B. Ask the patient to lock the item with other valuables in the hospital’s safe.
- C. Tell the patient that a family member should take valuables home.
- D. No action is necessary.
Correct answer: Ask the patient about the item and its significance.
Rationale: The small charm tied to a leather strip is likely an amulet, which many cultures consider an important means of protection from 'evil spirits.' When a patient appears to have a health practice the nurse is unfamiliar with, the nurse should ask for clarification in a non-judgmental way that communicates acceptance of their beliefs and allows for open communication. Thus, the nurse in this situation should inquire about the amulet’s meaning to the patient. Asking the patient to lock the item with other valuables in the hospital’s safe, telling the patient that a family member should take valuables home, or doing nothing does not address the importance or meaning of a cultural health practice to the patient and does not allow the nurse to gain an understanding of the patient’s cultural health practices.
4. What is the first aid for frostbite?
- A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
- B. Run warm water over the area to rapidly rewarm the affected area.
- C. Run hot water over the area to warm the area as quickly as possible.
- D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.
Correct answer: Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.
5. Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?
- A. ''I just want to stab myself with this pen.''
- B. ''What's the point in life anyways?''
- C. ''My thoughts are racing because of the conspiracies against me.''
- D. ''I hear voices every day and sometimes see old friends that don't exist.''
Correct answer: ''My thoughts are racing because of the conspiracies against me.''
Rationale: The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.
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