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NCLEX RN Exam Questions
1. Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?
- A. Weight loss of 2 lb (1 kg)
- B. Positive urine pregnancy test
- C. Hemoglobin level of 10.4 g/dL
- D. Complaints of nausea and anorexia
Correct answer: Positive urine pregnancy test
Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.
2. A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?
- A. Client will verbalize that depression symptoms have lifted
- B. Client will identify life stressors that may be contributing to depression
- C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
- D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy
Correct answer: Client will identify life stressors that may be contributing to depression
Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management. Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.
3. A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct answer: The infant received mechanical ventilation for 2 weeks
Rationale: The correct answer is 'The infant received mechanical ventilation for 2 weeks.' Bronchopulmonary dysplasia is a condition primarily caused by therapies like positive-pressure ventilation used in the treatment of lung disease. This leads to lung damage and subsequent respiratory problems. Choices A, B, and C are not consistent with the diagnosis of bronchopulmonary dysplasia. Gestational age assessment suggesting growth retardation is more indicative of intrauterine growth restriction, clearing meconium from the airway at delivery is related to potential respiratory issues at birth, and phototherapy for Rh incompatibility is unrelated to bronchopulmonary dysplasia.
4. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?
- A. Interview a family member instead.
- B. Wait for the patient to answer the questions.
- C. Remind the patient that you have other patients who need care.
- D. Give the patient an assessment form listing the questions and a pen.
Correct answer: Wait for the patient to answer the questions.
Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.
5. The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary healthcare provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period?
- A. Monitor the temperature.
- B. Monitor the blood pressure.
- C. Reposition the infant frequently.
- D. Aspirate the NG tube every 5 to 10 minutes.
Correct answer: Aspirate the NG tube every 5 to 10 minutes.
Rationale: Esophageal atresia with tracheoesophageal fistula is a critical neonatal surgical emergency. The highest priority intervention during the preoperative period is to aspirate the NG tube every 5 to 10 minutes to keep the proximal pouch clear of secretions and prevent aspiration. This is crucial in reducing the risk of gastric secretions entering the lungs. Repositioning the infant frequently is not as critical as ensuring the NG tube is aspirated. Monitoring the temperature and blood pressure are important nursing interventions but are not the highest priority in this situation. It is essential to prioritize airway protection and prevent aspiration in this neonate undergoing urgent surgical intervention.
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