NCLEX NCLEX-PN
Best NCLEX Next Gen Prep
1. Which of the following physical findings indicates that an 11–12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct answer: not pulling to a standing position
Rationale: The correct answer is 'not pulling to a standing position.' An 11–12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.
2. A client complaining of chest pain is prescribed an intravenous infusion of nitroglycerin (Nitro-Bid). After the infusion is initiated, the occurrence of which symptom warrants the nurse discontinuing an intravenous infusion of nitroglycerin?
- A. Frontal headache
- B. Orthostatic hypotension
- C. Decrease in intensity of chest pain
- D. Cool clammy skin
Correct answer: Cool clammy skin
Rationale: The correct answer is 'Cool clammy skin.' This assessment finding indicates decreased cardiac output that could result from excessive vasodilation. Cool clammy skin is a sign of poor perfusion, suggesting that the blood pressure might be dropping too low. Discontinuing the nitroglycerin infusion is crucial to prevent further complications. Choice A, 'Frontal headache,' is a common side effect of nitroglycerin but not a reason to discontinue the infusion unless severe or persistent. Choice B, 'Orthostatic hypotension,' may occur as a side effect of nitroglycerin but does not necessarily warrant discontinuation unless severe. Choice C, 'Decrease in intensity of chest pain,' is actually an expected therapeutic response to nitroglycerin and indicates improved myocardial perfusion, so it is not a reason to stop the infusion.
3. The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?
- A. “I will continue to report my pain score during assessments.”
- B. “I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button.”
- C. “I believe this new PCA pump will finally alleviate my back pain.”
- D. “I have more control over when and how much medication I receive.”
Correct answer: “I believe this new PCA pump will finally alleviate my back pain.”
Rationale: The correct answer is, “I believe this new PCA pump will finally alleviate my back pain.” This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.
4. What is the most common cause of acute renal failure?
- A. Shock
- B. Nephrotoxic drugs
- C. Enlarged prostate
- D. Diabetes
Correct answer: A
Rationale: The correct answer is 'Shock.' Acute renal failure is commonly caused by inadequate blood flow to the kidneys, which can occur in cases of shock. This leads to decreased kidney function and potential kidney damage. While nephrotoxic drugs can also cause acute renal failure, shock is the primary and most common cause. An enlarged prostate may lead to obstructive uropathy but is not the most prevalent cause of acute renal failure. Diabetes is typically associated with chronic kidney disease rather than acute renal failure.
5. Which microorganism is most commonly associated with gastritis?
- A. Syphilis
- B. Cytomegalovirus
- C. H. pylori
- D. Mycobacterium
Correct answer: C
Rationale: H. pylori is the most common microorganism associated with gastritis, present in over 80% of cases. While syphilis, cytomegalovirus, and mycobacterium can also cause gastritis, they are much less prevalent compared to H. pylori. Therefore, the correct answer is H. pylori.
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