NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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.
Question 2 of 5
Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, amylase levels are typically elevated. Monitoring amylase levels helps assess the effectiveness of therapy in managing the condition. Elevated amylase is a key indicator of pancreatic inflammation. Calcium (
Choice
A) levels may be affected in pancreatitis, but they are not the primary indicator for evaluating therapy effectiveness. Bilirubin (
Choice
B) and Potassium (
Choice
D) levels may also be altered in pancreatitis, but they are not specific markers for monitoring therapy response in acute pancreatitis.
Question 3 of 5
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
Correct Answer: A
Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.
Question 4 of 5
When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?
Correct Answer: B
Rationale: When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.
Question 5 of 5
A client has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?
Correct Answer: D
Rationale: A client diagnosed with active tuberculosis should be placed in isolation in a negative-pressure room to prevent transmission of infection to others. Placing the client in a negative-pressure room ensures that air is exhausted to the outside and received from surrounding areas, preventing tuberculin particles from traveling through the ventilation system and infecting others. Initiating standard precautions, as mentioned in choice C, is essential for infection control but is not specific to preventing transmission in the case of tuberculosis. Beginning drug therapy within 72 hours of diagnosis, as in choice A, is crucial for the treatment of tuberculosis but does not directly address preventing transmission. Placing the client in a positive-pressure room, as in choice B, is incorrect as positive-pressure rooms are used for clients with compromised immune systems to prevent outside pathogens from entering the room, which is not suitable for a client with active tuberculosis.