NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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 2 of 5
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
Correct Answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life.
Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
Question 3 of 5
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?
Correct Answer: D
Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.
Question 4 of 5
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
Correct Answer: B
Rationale: The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time.
Choice A is incorrect as abnormal drainage should be reported.
Choice C is incorrect as most patients can resume normal activities within a few days to a week.
Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.
Question 5 of 5
To palpate the liver during a head-to-toe physical assessment, the nurse should
Correct Answer: C
Rationale:
To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.