Questions 9

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Exam Questions Questions

Question 1 of 5

Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?

Correct Answer: B

Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.

Question 2 of 5

What should the nurse in the emergency department do first for a new patient who is vomiting blood?

Correct Answer: C

Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.

Question 3 of 5

During a physical exam, a healthcare professional assisting a client suspected of having meningitis bends the client's leg at the hip to a 90-degree angle. When attempting to extend the leg at the knee, the client experiences severe pain. What type of test is being performed?

Correct Answer: C

Rationale: The healthcare professional is performing Kernig's sign, a test for meningeal irritation often seen in meningitis cases. Kernig's sign involves bending the client's leg at a 90-degree angle at the hip and then attempting to extend the leg at the knee. Severe pain during this maneuver indicates a positive Kernig's sign, suggesting irritation of the meningeal membranes. Brudzinski's sign involves flexing the neck causing involuntary flexion of the hips and knees; Romberg's sign assesses balance and proprioception; Babinski's sign checks for abnormal reflexes in the foot.

Question 4 of 5

A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize:

Correct Answer: B

Rationale: The correct answer is administration of thyroid hormone will prevent problems. In newborns diagnosed with hypothyroidism, early identification and continuous treatment with hormone replacement can correct this condition effectively. Choice A is incorrect as it uses outdated and inappropriate language (mentally retarded) and does not reflect modern understanding of conditions. Choice C is incorrect because while some cases of hypothyroidism can be hereditary, it is not always the case. Choice D is incorrect as physical growth and development can be affected by hypothyroidism, but the critical emphasis should be on the importance of administering thyroid hormone to prevent complications and support normal growth and development.

Question 5 of 5

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is

Correct Answer: C

Rationale: Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that involves compressing plaque against the wall of a diseased coronary artery to improve blood flow. It is a minimally invasive procedure performed during a cardiac catheterization to open blockages in the coronary arteries. Surgical repair of a diseased coronary artery refers to procedures like coronary artery bypass grafting (CABG), not PTCA. Placement of an automatic internal cardiac defibrillator is a different intervention used for managing cardiac arrhythmias, not for improving coronary blood flow. A non-invasive radiographic examination of the heart would typically refer to procedures like a cardiac CT scan or an MRI, not PTCA.

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