NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A patient with severe Gastroesophageal Reflux Disease is receiving discharge teaching. Which of these statements by the patient indicates a need for more teaching?
Correct Answer: A
Rationale: The correct answer is ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.'' This statement indicates a need for more teaching because large meals increase the volume and pressure in the stomach, delaying gastric emptying, and worsening symptoms of Gastroesophageal Reflux Disease (GER
D). The recommended approach is to eat smaller, more frequent meals (4-6 small meals a day) to reduce acid reflux.
Choices B, C, and D demonstrate good understanding of GERD management by highlighting the importance of staying upright after meals, avoiding trigger foods like tea, coffee, and chocolate, and addressing weight management, which are all appropriate strategies to manage GERD symptoms.
Question 2 of 5
A 30-year-old woman is experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?
Correct Answer: C
Rationale: In a situation where a patient is experiencing anaphylaxis, it is crucial to act swiftly. Asking the woman if she carries an emergency medical kit is the most appropriate initial intervention. Many individuals with a history of anaphylaxis carry epinephrine auto-injectors, such as epi-pens, which can be life-saving in such situations. Initiating cardiopulmonary resuscitation (CPR) is not indicated as the patient is breathing but short of breath, and CPR is not the first-line intervention for anaphylaxis. Checking for a pulse, though important, is not the initial priority in managing anaphylaxis. Staying with the woman until help arrives is essential for providing support and monitoring her condition, but confirming the availability of an emergency medical kit takes precedence to promptly address the anaphylactic reaction.
Question 3 of 5
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
Correct Answer: D
Rationale: The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFL
D) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.
Question 4 of 5
Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals
Correct Answer: B
Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection.
Choices A, C, and D are incorrect because:
A) HBsAg indicates current infection with hepatitis B virus,
C) anti-HBc IgG suggests past infection or immunity, and
D) anti-HBc IgM is a marker of acute hepatitis B infection.
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.