NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?
Correct Answer: D
Rationale: The correct answer is 'Abdominal pain is decreased.' In a patient with acute pancreatitis, the goal of using an NG tube for suction and keeping the patient NPO is to decrease the release of pancreatic enzymes and alleviate pain.
Therefore, a decrease in abdominal pain would indicate the effectiveness of these therapies. Bowel sounds being present do not necessarily indicate treatment effectiveness, as they can still be present even if the therapies are not fully effective. Normal electrolyte levels are important but do not directly reflect the efficacy of NG suction and NPO status. The resolution of Grey Turner sign, a bruising over the flanks associated with pancreatitis, is a late and non-specific finding and waiting for it to resolve is not a reliable indicator of treatment effectiveness.
Question 2 of 5
A 34-year-old patient with chronic hepatitis C infection has several medications prescribed. Which medication requires further discussion with the healthcare provider before administration?
Correct Answer: B
Rationale: The correct answer is B: Pegylated α-interferon (PEG-Intron, Pegasys) SQ weekly. Pegylated α-interferon is typically administered once weekly, not daily.
Therefore, this medication requires further discussion with the healthcare provider before administration to ensure the correct dosing frequency. Ribavirin, choice A, is appropriate for chronic hepatitis C treatment.
Choices C and D, Diphenhydramine and Dimenhydrinate, are commonly used for symptomatic relief in patients with hepatitis C and do not require further discussion with the healthcare provider in this context.
Question 3 of 5
The healthcare provider is managing a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be immediately reported to the healthcare provider?
Correct Answer: D
Rationale: The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.
Question 4 of 5
A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?
Correct Answer: B
Rationale: The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.
Question 5 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.