NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?
Correct Answer: C
Rationale: 1. Increase in Forced Vital Capacity (FV
C): Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC.
Therefore, this choice is incorrect. 2. A widened chest cavity: A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Hence, a narrowed chest cavity is not an expected finding. 3. Clubbed fingers - CORRECT: Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels, which is commonly seen in patients with chronic respiratory conditions like Emphysema and Chronic Bronchitis. 4. An increased risk of cardiac failure: Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding, making it an incorrect choice.
Question 2 of 5
Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
Correct Answer: A
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation.
Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine.
Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability.
Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
Question 3 of 5
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
Correct Answer: A
Rationale: After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.
Question 4 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 5 of 5
When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
Correct Answer: C
Rationale: In this scenario, the nurse observed carpal spasms in the patient's right hand, indicating a positive Trousseau's sign, which is associated with hypocalcemia. Patients with acute pancreatitis are at risk for hypocalcemia, hence the nurse should promptly check the calcium level in the chart to assess the patient's condition. Notifying the healthcare provider comes after confirming the calcium level. There is no indication to ask about arm pain or to retake the blood pressure, as the primary concern is addressing the potential hypocalcemia.