NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
Correct Answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV.
Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes.
Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
Question 2 of 5
The healthcare professional in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the healthcare professional finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
Correct Answer: A
Rationale: The priority intervention in this scenario is to start a large-bore IV in the patient's arm. The patient's low blood pressure (95/60) and elevated pulse rate (110 beats per minute) indicate a potential hemorrhage, requiring immediate fluid resuscitation. Starting a large-bore IV will allow for rapid administration of fluids to stabilize the patient's condition. Asking for a stool sample, preparing to insert an NG tube, or administering morphine sulfate should not take precedence over addressing the hemodynamic instability and potential hemorrhage observed in the patient. These actions may be considered later in the patient's care, but the primary focus should be on addressing the critical issue of fluid replacement and stabilization.
Question 3 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 4 of 5
During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
Correct Answer: C
Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma.
Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma.
Choice B is incorrect because specific visual field deficits are more common than complete loss on one side.
Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.
Question 5 of 5
Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (
Choice
A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (
Choice
B) and Potassium (
Choice
D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.