NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?
Correct Answer: C
Rationale: The best indicator that propranolol has been effective in a patient with cirrhosis and esophageal varices is when the stools test negative for occult blood. Propranolol is prescribed to decrease the risk of bleeding from esophageal varices. This medication's effectiveness is primarily assessed by the absence of blood in the stools, indicating a reduction in the risk of bleeding from the varices. Monitoring for chest pain, blood pressure control, and a decrease in heart rate are important parameters in other conditions treated with propranolol, such as hypertension, angina, and tachycardia, but in this particular case, the absence of occult blood in the stools is the most relevant indicator of treatment success.
Question 2 of 5
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is
Correct Answer: A
Rationale: In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.
Question 3 of 5
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
Correct Answer: C
Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation.
Choice A, 'Back Pain,' is not a common side effect of heparin.
Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions.
Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.
Question 4 of 5
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
Correct Answer: C
Rationale: The correct preparation for an Intravenous Pyelogram (IVP) involves administering a laxative to the client the evening before the examination. This is crucial to ensure adequate bowel preparation, which in turn allows for better visualization of the bladder and ureters during the procedure. An IVP is an x-ray exam that utilizes contrast material to evaluate the kidneys, ureters, and bladder, aiding in the diagnosis of conditions like blood in the urine or pain in the side or lower back. Administering a laxative helps in achieving optimal imaging quality, which is essential for accurate diagnosis and subsequent treatment planning.
Choice A is incorrect because maintaining a regular diet is not the standard preparation for an IVP.
Choice B is incorrect as fluid intake is not typically restricted for this procedure.
Choice D is incorrect as an IVP involves multiple x-rays to assess the urinary system, not just one of the abdomen.
Question 5 of 5
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
Correct Answer: B
Rationale: The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.