NCLEX-RN
NCLEX RN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
A patient underwent fiberoptic colonoscopy 18 hours ago and presents to the emergency department with increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern?
Correct Answer: A
Rationale: The correct answer is bowel perforation. Bowel perforation is the most serious complication of fiberoptic colonoscopy, with signs such as progressive abdominal pain, fever, chills, and tachycardia indicating advancing peritonitis. Although colonoscopic perforation is rare (0.03% to 0.7% incidence), it can lead to high mortality and morbidity rates. Viral gastroenteritis (
Choice
B) typically presents with symptoms like diarrhea, nausea, vomiting, and abdominal cramps, but it is not the most immediate concern in this scenario. Colon cancer (
Choice
C) and diverticulitis (
Choice
D) are important conditions but are less likely to present acutely after colonoscopy compared to bowel perforation.
Question 2 of 5
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
Correct Answer: C
Rationale: A tall peaked T wave is a characteristic EKG pattern associated with hyperkalemia. Hyperkalemia refers to high levels of potassium in the blood, which can lead to cardiac arrhythmias and other serious complications. Tall peaked T waves are a red flag for potential cardiac issues and can indicate the need to discontinue potassium infusions. The other choices, such as narrowed QRS complex, shortened "PR"? interval, and prominent "U"? waves, are not typically associated with hyperkalemia.
Therefore, recognizing tall peaked T waves is crucial for the nurse to take prompt action in managing the client's condition.
Question 3 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 4 of 5
A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
Correct Answer: C
Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever.
Therefore, this description is not correct in the context of scarlet fever.
Question 5 of 5
What intervention should the nurse implement while a client is having a grand mal seizure?
Correct Answer: B
Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.