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NCLEX RN Practice Questions Exam Cram
1. What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?
- A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
- B. The nurse orders meals with adequate protein and calcium for the patient.
- C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
- D. The nurse administers oral painkillers as ordered.
Correct answer: The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
Rationale: The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.
2. The client is a 35-year-old multiparous individual scheduled for a tubal ligation. The nurse assesses the client's emotional response to the planned procedure. Which factor in the client’s history will contribute to the healthy resolution of any emotional problem associated with sterilization?
- A. Belief that the surgery will relieve her monthly dysmenorrhea
- B. Knowledge that her partner does not want to have any more children
- C. Feeling that her family is complete and she now has the children she planned for
- D. Recovery from her previous complicated birth and a desire to avoid another birth
Correct answer: Feeling that her family is complete and she now has the children she planned for
Rationale: The correct answer is feeling that her family is complete and she now has the children she planned for. Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should not be expected to have an effect on dysmenorrhea. The decision to undergo sterilization should be the individual's own choice and should not be influenced by others, including partners. Decisions regarding sterilization should ideally be made when the individual is not under stress, such as after recovery from a previous complicated birth. Therefore, the key factor contributing to a healthy resolution of emotional issues related to sterilization is the feeling of family completeness and achieving the planned number of children.
3. Which of the following questions is considered open-ended?
- A. What time did you last take your medications?
- B. Are you feeling okay right now?
- C. Please describe your symptoms.
- D. What day are you available for a follow-up appointment?
Correct answer: Please describe your symptoms.
Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses. Choice A is a closed-ended question since it seeks a specific time for the medication intake. Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response. Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.
4. The client believes that the illness is a punishment for sins. Which cultural health belief is the client communicating?
- A. Yin/Yang balance
- B. Biomedical belief
- C. Determinism belief
- D. Magicoreligious belief
Correct answer: Magicoreligious belief
Rationale: The client is communicating a magicoreligious belief by attributing the illness to punishment for sins. In this belief system, illness is seen as caused by supernatural forces or hexes, often related to spiritual or religious beliefs. The yin/yang balance belief system does not view illness as punishment but rather as an imbalance of opposing forces. Biomedical belief focuses on physical and biochemical processes as the cause of health and illness. Determinism belief revolves around outcomes being preordained and unchangeable, not related to punishment for sins.
5. A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms?
- A. Anesthesia reaction
- B. Hyperglycemia
- C. Hypoglycemia
- D. Diabetic ketoacidosis
Correct answer: Hypoglycemia
Rationale: In a postoperative diabetic patient who is unable to eat solid foods, the likely cause of symptoms such as confusion and shakiness is hypoglycemia. Confusion and shakiness are common manifestations of hypoglycemia. Insufficient glucose supply to the brain (neuroglycopenia) can lead to confusion, difficulty with concentration, irritability, hallucinations, focal impairments like hemiplegia, and, in severe cases, coma and death. Anesthesia reaction (Choice A) is less likely in this scenario as the patient is already on the second postoperative day. Hyperglycemia (Choice B) is unlikely given the patient's symptoms and history of not eating. Diabetic ketoacidosis (Choice D) typically presents with hyperglycemia, ketosis, and metabolic acidosis, which are not consistent with the patient's current symptoms of confusion and shakiness.
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