NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
Correct Answer: D
Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
Question 2 of 5
In an interview for suspected child abuse, the child's mother openly discusses her feelings. She feels her husband is too aggressive in disciplining their child. The child's father states, 'Being a school custodian, I see kids every day that are bad because they did not get enough discipline at home. That will not happen to our child.' Based on this remark, the nurse would make the following nursing diagnosis:
Correct Answer: D
Rationale: There is no evidence of fear as the child is unable to communicate. There is actual injury, but the parents have not yet admitted causing the child's injuries. This diagnosis is incomplete. There is no specific ineffective coping behavior identified in this nursing diagnosis. Altered family process best describes the family dynamics in this situation. The parents have admitted severe disciplinary action.
Question 3 of 5
The nurse is performing an assessment on a client with a history of a tension pneumothorax. Which finding is most concerning?
Correct Answer: A
Rationale: Tracheal deviation in a tension pneumothorax indicates mediastinal shift from increased intrathoracic pressure, a life-threatening emergency requiring immediate attention.
Question 4 of 5
Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of:
Correct Answer: A
Rationale: Tetralogy of Fallot is the most common cyanotic heart defect, which includes a VSD, pulmonary stenosis, an overriding aorta, and ventricular hypertrophy. The blood flow is obstructed because the pulmonary stenosis decreases the pulmonary blood flow and shunts blood through the VSD, creating a right-to-left shunt that allows deoxygenated blood to reach the systemic circulation. A VSD alone creates a left-to-right shunt. The pressure in the left ventricle is greater than that of the right; therefore, the blood will shunt from the left ventricle to the right ventricle, increasing the blood flow to the lungs. No deoxygenated blood will reach the Systemic circulation. In patent ductus arteriosus, the pressure in the aorta is greater than in the pulmonary artery, creating a left-to-right shunt. Oxygenated blood from the aorta flows into the unoxygenated blood of the pulmonary artery. Transposition of the great arteries results in two separate and parallel circulatory systems. The only mixing or shunting of blood is based on the presence of associated lesions.
Question 5 of 5
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
Correct Answer: B
Rationale: Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. Axillary node status is the most important indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. The client's previous history of cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. The estrogen-progesterone assay test is used to identify present tumors being fed from an estrogen site within the body. Some breast cancers grow rapidly as long as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.