NCLEX NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?
- A. Interpret that the patient is eager and interested in participating in the interview.
- B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
- C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
- D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Correct answer: Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Rationale: Assuming a tripod position—leaning forward with arms braced on chair arms—occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.
2. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?
- A. EEG
- B. EKG
- C. Electrolytes
- D. Echocardiogram
Correct answer: Electrolytes
Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.
3. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
- A. Collaborating with the client to establish healthcare goals
- B. Reviewing the client's medical record history
- C. Explaining the purpose of administered medications to the client
- D. Rapidly resetting priorities for client care based on changes in the client's condition
Correct answer: D: Rapidly resetting priorities for client care based on changes in the client's condition
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
4. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal at least 2-3 hours before bedtime
- C. Take sodium bicarbonate after each meal
- D. Sleep with head propped on several pillows
Correct answer: D: Sleep with head propped on several pillows
Rationale: During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.
5. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
- A. Assist the client in using the bathroom one hour after going to bed
- B. Give the client a massage before bedtime
- C. Tuck bed sheets and blankets tightly around the client once settled in bed
- D. Give the client a pair of socks to wear if their feet become cold
Correct answer: Give the client a pair of socks to wear if their feet become cold
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
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