NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A patient's chart indicates a history of meningitis. Which of the following would you NOT expect to see with this patient if this condition were acute?
Correct Answer: A
Rationale: The correct answer is 'Increased appetite.' In cases of acute meningitis, loss of appetite would be expected rather than an increase. Meningitis is often caused by an infectious agent that colonizes or infects various sites in the body, leading to systemic symptoms. Common symptoms of acute meningitis include fever, vomiting, and poor tolerance of light due to meningeal irritation. The inflammatory response in the meninges can result in symptoms like photophobia. Increased appetite is not typically associated with acute meningitis.
Therefore, choice A is the least likely symptom to be observed in a patient with acute meningitis.
Choices B, C, and D are symptoms commonly seen in acute meningitis due to the inflammatory process affecting the central nervous system and meninges.
Question 2 of 5
A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?
Correct Answer: B
Rationale: Cardiac tamponade occurs when fluid or blood accumulates in the pericardium, preventing the heart from contracting properly. This leads to decreased cardiac output and is considered a medical emergency. Classic signs of cardiac tamponade include hypotension (low blood pressure) and distended neck veins due to the increased pressure around the heart. These signs result from the compromised ability of the heart to pump effectively.
Choices A, C, and D are not typically associated with cardiac tamponade. Fever, fatigue, and malaise are non-specific symptoms that can be seen in various conditions. Cough and hemoptysis are more commonly associated with respiratory conditions, while numbness and tingling in the extremities are neurological symptoms not typically seen in cardiac tamponade.
Question 3 of 5
A nurse is assessing a client who is post-op day #3 after an abdominal hernia repair. After a bout of harsh coughing, the client states, 'it feels like something gave way.' The nurse assesses his abdomen and notes an evisceration from the surgical site. What is the next action of the nurse?
Correct Answer: D
Rationale: A wound evisceration occurs when the edges of an abdominal wound separate, allowing the coils of the intestine to protrude outside of the body. The nurse should notify the physician at once if this occurs. While waiting for treatment, the nurse should cover the intestines with sterile gauze soaked in saline. Turning the client on his side or asking the client to take a breath and hold it are not appropriate actions in this situation. Pushing the abdominal contents back inside the wound using sterile gloves can lead to infection and is not within the nurse's scope of practice.
Question 4 of 5
A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?
Correct Answer: C
Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions.
Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.
Question 5 of 5
A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure?
Correct Answer: C
Rationale: The correct answer is a patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator is used to deliver an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. These patients are at high risk of life-threatening arrhythmias, which may result in syncope. Patients with atrial tachycardia and fatigue (
Choice
D) would not typically require an implantable cardioverter-defibrillator as their primary issue is related to atrial arrhythmias. Patients who have had a myocardial infarction without cardiac muscle damage (
Choice
A) or postoperative coronary bypass patients recovering on schedule (
Choice
B) are not necessarily at high risk for ventricular arrhythmias and would not be the primary candidates for an implantable cardioverter-defibrillator.