NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
Correct Answer: D
Rationale: Mild PIH is not treated with medications. Emotional stress is not the cause of blood pressure elevation in PIH. Excessive caloric intake is not the cause of weight gain in PIH. The client most frequently is not aware of the signs and symptoms in mild PIH.
Question 2 of 5
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (
A) to keep oil against the retina, head bowed when upright (
D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (
B) is not strict, and diet (
C) progresses as tolerated.
Question 3 of 5
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
Correct Answer: B
Rationale: This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
Question 4 of 5
A client is admitted with suspected pneumothorax. Which finding is most significant in confirming the diagnosis?
Correct Answer: A
Rationale: Tracheal deviation to the unaffected side is a hallmark of tension pneumothorax, indicating mediastinal shift due to air trapping, confirming the diagnosis.
Question 5 of 5
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.