NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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.
Question 2 of 5
A patient with severe Gastroesophageal Reflux Disease is receiving discharge teaching. Which of these statements by the patient indicates a need for more teaching?
Correct Answer: A
Rationale: The correct answer is ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.'' This statement indicates a need for more teaching because large meals increase the volume and pressure in the stomach, delaying gastric emptying, and worsening symptoms of Gastroesophageal Reflux Disease (GER
D). The recommended approach is to eat smaller, more frequent meals (4-6 small meals a day) to reduce acid reflux.
Choices B, C, and D demonstrate good understanding of GERD management by highlighting the importance of staying upright after meals, avoiding trigger foods like tea, coffee, and chocolate, and addressing weight management, which are all appropriate strategies to manage GERD symptoms.
Question 3 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.
Question 4 of 5
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
Correct Answer: B
Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments.
Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition.
Choice C, abstaining from substance use, is important but not as crucial as medication adherence.
Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.
Question 5 of 5
A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?
Correct Answer: C
Rationale: Necrotizing enterocolitis (NE
C) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician.
Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered.
Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC.
Choice B, positioning the infant on his back, is not directly related to the treatment of NEC.
Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.