NCLEX NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
- A. The nurse uses a pen pad to communicate with the patient
- B. The nurse provides oral care every 2 hours
- C. The nurse listens for bowel sounds every 4 hours
- D. The nurse suctions as needed and elevates the head of the bed
Correct answer: The nurse suctions as needed and elevates the head of the bed
Rationale: The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.
2. The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
- A. Lymphatic System
- B. Digestive System
- C. Urinary System
- D. Respiratory System
Correct answer: Lymphatic System
Rationale: The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
3. Which of the following diseases is caused by the Bordetella pertussis bacterium?
- A. German Measles
- B. RSV
- C. Meningitis
- D. Whooping Cough
Correct answer: Whooping Cough
Rationale: Bordetella pertussis is the bacterium responsible for causing Whooping Cough, also known as pertussis. Meningitis can be caused by various bacteria, but not specifically by Bordetella pertussis. German Measles, also known as Rubella, and RSV (Respiratory Syncytial Virus) are viral infections and are not caused by the Bordetella pertussis bacterium. Therefore, the correct answer is Whooping Cough, caused by Bordetella pertussis.
4. Which feeling would be difficult for a client with major depression to express?
- A. Need for comforting
- B. Anger toward others
- C. Remorse for past behaviors
- D. Feelings of low self-esteem
Correct answer: Anger toward others
Rationale: Clients with major depression often have difficulty expressing anger toward others as their anger is typically directed inwards. Expressing the need for comforting is common among clients with major depression. They can also articulate remorse for past behaviors to an excessive degree. Furthermore, feelings of low self-esteem can be openly expressed by clients with major depression. Therefore, the difficulty in expressing anger toward others is the most appropriate choice as clients with major depression tend to internalize their anger.
5. The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?
- A. Call for a cardiac evaluation and implement appropriate measures
- B. Check the patient's oxygen saturation
- C. Inform the physician about the elevated BNP level
- D. Encourage the patient to limit physical activity
Correct answer: Check the patient's oxygen saturation
Rationale: An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.
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