NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A 3-year-old child is in the burn unit following a home accident. The first sign of sepsis in burned children is:
Correct Answer: A
Rationale: Disorientation is the first sign of sepsis in burn children. Low-grade fever is not indicative of sepsis. Diarrhea is not indicative of sepsis. Hypertension is not indicative of sepsis.
Question 2 of 5
A client with a history of a thyroidectomy is being discharged. The nurse should teach the client to:
Correct Answer: A
Rationale: Hypocalcemia post-thyroidectomy (due to parathyroid damage) causes symptoms like tingling or tetany, requiring monitoring. Iodine foods, bedtime dosing, and fluid limits are not primary concerns.
Question 3 of 5
Which of the following ECG changes would be seen as a positive myocardial stress test response?
Correct Answer: C
Rationale: Hyperacute T waves occur with hyperkalemia. Prolongation of the PR interval occurs with first-degree AV block. Horizontal ST-segment depression of >1 mm during exercise is definitely a positive criterion on the exercise ECG test. Pathological Q waves occur with MI.
Question 4 of 5
The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:
Correct Answer: D
Rationale: The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
Question 5 of 5
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
Correct Answer: A
Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.