NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.
Correct Answer: D
Rationale: The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. In this case, monitoring the albumin level is crucial to assess the patient's fluid balance and potential for edema. While hemoglobin, temperature, and activity level are important parameters to monitor in a patient's assessment, they are not directly associated with the patient's current symptoms of toxic hepatitis and edema development.
Therefore, the correct choice is the albumin level.
Question 2 of 5
Which of the following types of dressing changes works as a form of wound debridement?
Correct Answer: D
Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement.
Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound.
Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement.
Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.
Question 3 of 5
Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
Correct Answer: C
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.
Question 4 of 5
What should the nurse in the emergency department do first for a new patient who is vomiting blood?
Correct Answer: C
Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern.
Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.
Question 5 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.