you have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines when checke
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NCLEX-RN

NCLEX RN Exam Review Answers

1. You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?

Correct answer: D

Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments. Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.

2. A nurse is providing dismissal instructions for a child who was admitted for rotavirus. Which of the following statements by the parent indicates the need for further teaching?

Correct answer: A

Rationale: The correct answer is 'I'll start giving him his antibiotics as soon as we get home.' Rotavirus is a viral illness, and antibiotics are ineffective for its treatment. The parent's statement indicates a need for further teaching as antibiotics are not appropriate for treating rotavirus. Option B is correct as it demonstrates the parent's understanding of when to contact the physician for concerning symptoms. Option C is a correct statement regarding infection control practices. Option D is also correct as monitoring diarrhea stools is essential to track recovery from rotavirus.

3. A client is having blood tests and has an elevated lymphocyte level. Based on knowledge of cellular components, what does the nurse know about these cells?

Correct answer: C

Rationale: Lymphocytes are a type of white blood cells that play a crucial role in supporting the body's immune system. They are responsible for producing substances that protect the body against infections and foreign substances that could potentially harm the client. Lymphocytes consist of two main types: T cells, which are produced in the thymus, and B cells, which are produced in the lymphatic tissue. Choice A is incorrect because histamine is mainly associated with basophils and mast cells, not lymphocytes. Choice B is incorrect as phagocytosis is a function of other white blood cells such as neutrophils and macrophages. Choice D is also incorrect as carrying hemoglobin and oxygen is a function of red blood cells, not lymphocytes.

4. A client returns from surgery after having a colon resection. The nurse is performing an assessment and notes the wound edges have separated. This condition is called:

Correct answer: C

Rationale: Wound dehiscence occurs when the edges of a wound pull apart. The condition may occur following a surgical procedure if the sutures were deficient. Wound dehiscence may also occur following a wound infection or in cases where a client significantly stretches or overuses the associated tissues. Evisceration refers to the protrusion of internal organs through an open wound. Hematoma is a localized collection of blood outside the blood vessels. Granulation is the formation of new connective tissue and tiny blood vessels on the surface of a wound during the healing process.

5. Sinusitis is caused by:

Correct answer: D

Rationale: Sinusitis can be caused by bacteria, viruses, or fungi. While bacterial infections are the most common cause, viral or fungal infections can also lead to sinusitis. Therefore, the correct answer is 'Any of the above.' Choices A, B, and C are incorrect because they only represent individual causes of sinusitis, whereas choice D encompasses all possible causes.

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