NCLEX-RN
NCLEX RN Exam Review Answers
1. Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?
- A. Pickle
- B. Wheat toast
- C. Baked chicken
- D. Steamed vegetables
Correct answer: A
Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.
2. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?
- A. "I should be experiencing less blurriness in my central field of vision"
- B. "This medication won't help my vision at all, but will keep it from getting worse."
- C. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
- D. "This medication will help my eye restor intraocular fluid and increase intraocular pressure"
Correct answer: B
Rationale: Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.
3. A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?
- A. The capillary refill time is 2 seconds
- B. The patient complains of itching and discomfort
- C. The cast has a foul-smelling odor
- D. The patient is on antibiotics
Correct answer: C
Rationale: A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.
4. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs.
- B. Massage the fundus.
- C. Offer a bedpan.
- D. Check for perineal lacerations.
Correct answer: B
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
5. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?
- A. Bronchial breath sounds are heard at the right base.
- B. The patient coughs up small amounts of green mucus.
- C. The patients white blood cell (WBC) count is 9000/L
- D. Increased tactile fremitus is palpable over the right chest
Correct answer: C
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
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