NCLEX NCLEX-RN
NCLEX RN Practice Questions With Rationale
1. When teaching a client with coronary artery disease about nutrition, what should the nurse emphasize?
- A. Eating three balanced meals a day
- B. Adding complex carbohydrates
- C. Avoiding very heavy meals
- D. Limiting sodium intake to 7 g per day
Correct answer: Avoiding very heavy meals
Rationale: The correct answer is to emphasize avoiding very heavy meals. Eating large, heavy meals can divert blood away from the heart for digestion, potentially endangering clients with coronary artery disease. This practice may lead to an increased risk of plaque accumulation in the arteries, potentially obstructing the delivery of blood and oxygen to vital organs. Choices A, B, and D are incorrect. While eating three balanced meals a day, adding complex carbohydrates, and limiting sodium intake are generally good dietary practices, they are not the primary focus when teaching a client with coronary artery disease about nutrition. The emphasis should be on avoiding heavy meals that can strain the cardiovascular system.
2. Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
- A. Absent bowel sounds
- B. Abdominal tenderness
- C. Left upper quadrant pain
- D. Palpable abdominal mass
Correct answer: Palpable abdominal mass
Rationale: The correct answer is a palpable abdominal mass. In a 46-year-old woman with acute pancreatitis, a palpable abdominal mass may indicate the presence of a pancreatic abscess, which requires rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common symptoms in acute pancreatitis but do not necessarily indicate an immediate need for surgical intervention. Therefore, the presence of a palpable abdominal mass is the most concerning finding in this scenario.
3. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct answer: Manage pain
Rationale: In the scenario presented, the priority nursing goal for a client with renal calculi experiencing moderate to severe flank pain and nausea should be to manage pain. Pain management is crucial as it alleviates suffering, improves comfort, and enhances the quality of life for the client. In the case of ureteral colic from renal calculi, the cornerstone of management is effective pain control. Prompt analgesia, typically achieved with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs), is essential to provide relief and facilitate the passage of the calculi. While maintaining fluid and electrolyte balance is important in clients with renal calculi, addressing pain takes precedence as it directly impacts the client's immediate well-being. Controlling nausea and preventing urinary tract infections are also important aspects of care, but they are secondary to managing the primary concern of pain in this urgent situation.
4. A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?
- A. Spasms of the tongue and face
- B. Orthostatic hypotension
- C. Dry mouth
- D. Increased appetite
Correct answer: Spasms of the tongue and face
Rationale: Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.
5. The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for lung cancer. Which information should the nurse include about the patient's postoperative care?
- A. Positioning on the right side
- B. Bed rest for the first 24 hours
- C. Frequent use of an incentive spirometer
- D. Chest tube placement with continuous drainage
Correct answer: Frequent use of an incentive spirometer
Rationale: After a pneumonectomy, frequent deep breathing and coughing are essential to prevent atelectasis and promote gas exchange. Patients are typically positioned on the surgical side to aid in gas exchange. Early mobilization is crucial to reduce the risk of postoperative complications such as pneumonia and deep vein thrombosis. While chest tubes may or may not be placed in the surgical space, if used, they are clamped and only adjusted by the surgeon to manage serosanguineous fluid accumulation. Overfilling of the chest cavity can compromise remaining lung function and cardiovascular status. Chest x-rays are useful for monitoring fluid volume and space postoperatively. Therefore, the correct postoperative care instruction for the patient undergoing a left pneumonectomy is the frequent use of an incentive spirometer. Choices A, B, and D are incorrect as positioning on the right side, bed rest for the first 24 hours, and continuous chest tube drainage are not standard postoperative care practices for patients undergoing pneumonectomy.
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