HESI RN
NCLEX RN Exam Questions
1. Which finding indicates to the nurse that lactulose (Cephulac) is effective for a 72-year-old man who has advanced cirrhosis?
- A. The patient is alert and oriented.
- B. The patient denies nausea or anorexia.
- C. The patient's bilirubin level decreases.
- D. The patient has at least one stool daily.
Correct answer: The patient is alert and oriented.
Rationale: The correct answer is 'The patient is alert and oriented.' In a patient with advanced cirrhosis, lactulose is used to lower ammonia levels and prevent encephalopathy. A patient being alert and oriented indicates that the medication is effective in achieving this goal. While lactulose may help with constipation, the primary purpose in cirrhosis is to reduce ammonia levels, not to address constipation directly. Denying nausea or anorexia is not a specific indicator of lactulose's effectiveness in treating cirrhosis. Bilirubin levels decreasing are not directly related to lactulose's therapeutic effect on cirrhosis.
2. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
- A. Cardiac arrhythmias.
- B. Hypertension.
- C. Seizures.
- D. Hypothermia.
Correct answer: A
Rationale: The correct answer is A: Cardiac arrhythmias. Reperfusion of cardiac tissue following t-PA administration can lead to cardiac arrhythmias, necessitating resuscitation equipment. Hypertension (choice B) is a common side effect of t-PA but is not directly related to reperfusion. Seizures (choice C) and hypothermia (choice D) are not typically associated with reperfusion from t-PA administration.
3. The healthcare provider is conducting a health assessment for a family in a rural area. Which intervention should the healthcare provider prioritize to address the family's health needs?
- A. Providing information on local healthcare resources
- B. Teaching the family about proper nutrition
- C. Assisting the family in scheduling medical appointments
- D. Connecting the family with transportation services
Correct answer: A
Rationale: In rural areas, access to healthcare may be limited. Providing information on local healthcare resources is essential to ensure the family can access necessary services. While proper nutrition (choice B) and medical appointments (choice C) are important, having access to healthcare resources is fundamental. Transportation services (choice D) may be helpful but addressing the availability of healthcare resources should be the priority.
4. Which of the following is NOT a phase of the menstrual cycle?
- A. Follicular phase
- B. Ovulatory phase
- C. Luteal phase
- D. Secretory phase
Correct answer: D
Rationale: The secretory phase is not considered a distinct phase of the menstrual cycle; it is actually part of the luteal phase. During the luteal phase, the endometrium thickens due to progesterone secretion, preparing for implantation. The follicular phase is characterized by follicle development, leading to ovulation. The ovulatory phase is when the mature egg is released from the ovary. Therefore, the secretory phase is the correct answer as it is not a standalone phase but a part of the luteal phase.
5. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?
- A. Evaluate the oxygen saturation.
- B. Administer a bronchodilator.
- C. Assist the client to sit upright.
- D. Encourage slow, deep breathing.
Correct answer: A
Rationale: In this scenario, the nurse should first evaluate the oxygen saturation. This action is crucial as it provides immediate information on the client's respiratory status. Assessing the oxygen saturation can help determine the adequacy of oxygenation and guide further interventions. Administering a bronchodilator (Choice B) may be necessary based on assessment findings, but it should not be the first action without knowing the oxygen saturation level. While assisting the client to sit upright (Choice C) is generally beneficial for respiratory function, in this case, assessing oxygen saturation takes precedence. Encouraging slow, deep breathing (Choice D) can be helpful, but it is secondary to evaluating the oxygen saturation in this situation.