NCLEX-RN
NCLEX RN Simulated Exam Test Bank Questions
Extract:
Question 1 of 5
The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period?
Correct Answer: A
Rationale: The most appropriate position for an infant after surgical intervention for imperforate anus is the prone position. Placing the infant in a prone position helps keep the hips elevated, reducing edema and pressure on the surgical site. This position promotes optimal healing and comfort for the infant. Option B, supine with no head elevation, does not provide the necessary elevation to reduce pressure on the surgical site. Option C, side-lying with the legs extended, does not offer the same benefits as the prone position in terms of reducing pressure on the surgical site. Option D, supine with the head elevated 45 degrees, does not specifically address the need for hip elevation to prevent pressure on the surgical site.
Therefore, the correct choice is the prone position for this postoperative care scenario.
Question 2 of 5
Mr. Thomas is a well-groomed 68-year-old male patient who had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?
Correct Answer: B
Rationale: The correct answer is that the weight gain may be due to the urinary drainage bag not being emptied today, while it was emptied on previous days. This scenario is common and can lead to an increase in weight that is not related to food intake.
Choice A is incorrect because assuming visitors are sneaking junk food is speculative and not based on facts.
Choice C is incorrect as there is no evidence to suggest the scale is broken.
Choice D is incorrect because any unexplained weight gain should be investigated further, even if it seems insignificant at first.
Question 3 of 5
In a 68-year-old man, a gradual loss of hearing is known as _____________.
Correct Answer: A
Rationale: The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.
Question 4 of 5
A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?
Correct Answer: A
Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension.
Choice A, 142/92, falls within this range, making it the correct answer.
Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension.
Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.
Question 5 of 5
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up."? Which nursing intervention should have the highest priority?
Correct Answer: D
Rationale: The highest priority nursing intervention in this scenario should be suicide precautions. The patient's statement indicates suicidal ideation, which poses an immediate risk to their safety. By implementing suicide precautions, the nurse can ensure constant monitoring and intervention to prevent any self-harm. While addressing self-esteem, anxiety, and sleep issues are essential, ensuring the patient's safety by prioritizing suicide precautions is crucial. Self-esteem-building activities, anxiety self-control measures, and sleep enhancement activities are important interventions but should follow the immediate concern of preventing harm from suicidal thoughts.