NCLEX NCLEX-RN
NCLEX RN Exam Questions
1. Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?
- A. Calcium
- B. Bilirubin
- C. Amylase
- D. Potassium
Correct answer: C: Amylase
Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (Choice A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (Choice B) and Potassium (Choice D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.
2. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
- A. Use sterile solution at room temperature
- B. Position the client in a comfortable position
- C. Clamp the catheter at the level above the injection port
- D. Inject sterile solution through the injection port into the catheter
Correct answer: Inject sterile solution through the injection port into the catheter
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
3. The nurse is examining a 2-year-old child and asks, “May I listen to your heart now?” Which critique of the nurse’s technique is most accurate?
- A. Asking questions may enhance the child’s autonomy.
- B. Asking the child for permission helps develop a sense of trust.
- C. This question is an inappropriate statement because children at this age like to have choices.
- D. Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available.
Correct answer: Children at this age like to say, “No.” The examiner should not offer a choice when no choice is available.
Rationale: Children at the age of 2 often like to assert their independence by saying “No.” In situations where there is actually no choice available, offering a false choice can lead to a lack of trust. It is important not to offer a choice when there isn't one, as doing so may undermine trust. While asking for permission can enhance autonomy and trust, offering a limited option like, “Shall I listen to your heart next or your tummy?” may be a better approach. Therefore, the correct critique of the nurse’s technique in this scenario is that children at this age tend to say “No,” so the examiner should avoid offering a choice when there isn't a real alternative.
4. A patient has been told to monitor her LH levels. Which of the following potential conditions might the patient be suffering from?
- A. Menorrhagia
- B. Grave's Disease
- C. Menopause
- D. Infertility
Correct answer: Infertility
Rationale: Luteinizing hormone (LH) is released by the pituitary gland to stimulate ovulation. One of the common reasons for monitoring LH levels is infertility. In women with infertility, LH levels are monitored to time intercourse accurately to maximize the chances of conception. Menorrhagia (choice A) is characterized by heavy menstrual bleeding and is not directly related to LH levels. Grave's Disease (choice B) is an autoimmune disorder affecting the thyroid gland and is not typically monitored by LH levels. Menopause (choice C) is a natural process marking the end of a woman's reproductive years and is not a condition where LH monitoring for infertility is common.
5. Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?
- A. The patient had a blood transfusion in 2005
- B. The patient used IV drugs about 20 years ago
- C. The patient frequently eats in fast-food restaurants
- D. The patient traveled to a country with poor sanitation
Correct answer: The patient used IV drugs about 20 years ago
Rationale: The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.
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