NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care?
Correct Answer: B
Rationale: The correct nursing action for a patient with balloon tamponade for bleeding esophageal varices is to monitor the patient for shortness of breath. The most common complication of balloon tamponade is aspiration pneumonia. Additionally, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Instructing the patient to cough every hour is incorrect as coughing increases the pressure on the varices and raises the risk of bleeding. Verifying the position of the balloon every 4 hours is unnecessary as it is typically done after insertion. Deflating the gastric balloon if the patient reports nausea is incorrect because deflating it may cause the esophageal balloon to occlude the airway, leading to complications.
Therefore, monitoring for signs of respiratory distress is crucial in this situation.
Question 2 of 5
To palpate the liver during a head-to-toe physical assessment, the nurse should
Correct Answer: C
Rationale:
To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.
Question 3 of 5
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?
Correct Answer: D
Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.
Question 4 of 5
A two-year-old child has sustained an injury to the leg and refuses to walk. The nurse in the emergency department documents swelling of the lower affected leg. Which of the following does the nurse suspect is the cause of the child's symptoms?
Correct Answer: A
Rationale: The child's refusal to walk, along with swelling of the lower leg, indicates a possible fracture, specifically of the tibia. Fractures can cause pain and swelling, leading to difficulty or refusal to bear weight on the affected limb.
Choice B, bruising of the gastrocnemius muscle, would not typically result in the child refusing to walk.
Choice C, a possible fracture of the radius, is less likely given the location of the swelling and the associated refusal to walk.
Choice D, stating no anatomic injury and attributing the child's behavior to wanting to be carried by the mother, is incorrect as the physical findings suggest a potential fracture that needs to be evaluated further.
Question 5 of 5
While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?
Correct Answer: A
Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (
Choice
B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (
Choice
C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (
Choice
D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.