NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the healthcare provider?
Correct Answer: B
Rationale: The correct answer is 'Liver edge 3 cm below the costal margin.' Normally, the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly, which could indicate an underlying health issue. Tympany on percussion of the abdomen, bowel sounds of 20/minute in each quadrant, and aortic pulsations visible in the epigastric area are all within normal limits for a physical assessment and do not require immediate reporting to the healthcare provider.
Question 2 of 5
Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals
Correct Answer: B
Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection.
Choices A, C, and D are incorrect because:
A) HBsAg indicates current infection with hepatitis B virus,
C) anti-HBc IgG suggests past infection or immunity, and
D) anti-HBc IgM is a marker of acute hepatitis B infection.
Question 3 of 5
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
Correct Answer: B
Rationale: In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.
Question 4 of 5
Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
Correct Answer: A
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation.
Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine.
Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability.
Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
Question 5 of 5
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
Correct Answer: B
Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments.
Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition.
Choice C, abstaining from substance use, is important but not as crucial as medication adherence.
Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.