NCLEX-RN
NCLEX RN Practice Questions Exam Cram Questions
Extract:
Question 1 of 5
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
Correct Answer: B
Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown.
Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.
Question 2 of 5
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
Correct Answer: C
Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (
Choice
A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (
Choice
B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (
Choice
D) is not relevant to the preparation process for an IVP.
Question 3 of 5
For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
Correct Answer: A
Rationale: Institute seizure precautions. The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications, and anticipatory preparation such as seizure precautions is needed. Weighing the child twice per shift may be necessary for monitoring fluid balance but is not specifically related to the complications of AGN. Encouraging the child to eat protein-rich foods is important for overall nutrition but does not directly address the potential complications of AGN. Relieving boredom through physical activity is beneficial for overall well-being but is not the priority in this situation where seizure precautions are essential.
Question 4 of 5
A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?
Correct Answer: D
Rationale: The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.
Question 5 of 5
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
Correct Answer: C
Rationale: In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.