NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
Which statement is true regarding a patient with a Sengstaken-Blakemore tube?
Correct Answer: D
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding. Scissors must be kept at the bedside to cut the tube in case of airway obstruction from balloon migration. The gastric balloon (not esophageal) controls bleeding the tube has three lumens and esophageal balloon pressure is typically 20-25 mmHg.
Question 2 of 5
The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which symptom is most likely to be present?
Correct Answer: A
Rationale: Ectopic pregnancy causes sudden abdominal pain from tubal stretching or rupture. Painless bleeding is more typical of placenta previa fetal heart tones are absent and fever is not common.
Question 3 of 5
During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior?
Correct Answer: D
Rationale: Play provides the child with opportunities for coping and adaptation. Aggression during play activities indicates a coping response to hospitalization.
Question 4 of 5
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?
Correct Answer: C
Rationale: Avoiding alcohol entirely, as indicated by attending AA meetings, shows understanding of preventing pancreatitis, which is often triggered by alcohol consumption.
Question 5 of 5
The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:
Correct Answer: B
Rationale: The IV line should not be discontinued because other IV medications will be needed. Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.