NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
Correct Answer: B
Rationale: Patients diagnosed with chronic hepatitis B are at a higher risk for developing liver cancer.
Therefore, it is essential to schedule them for liver cancer screening every 6 to 12 months to detect any potential malignancies at an early stage. Advising patients to limit alcohol intake is crucial as alcohol can exacerbate liver damage; thus, patients with chronic hepatitis B are advised to completely avoid alcohol. Administering the hepatitis C vaccine is irrelevant for a patient diagnosed with chronic hepatitis B since it is a different virus. Monitoring anti-hepatitis B surface antigen (anti-HBs) levels annually is not necessary as the presence of anti-HBs indicates a past hepatitis B infection or vaccination, and it does not require regular monitoring.
Question 2 of 5
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
Correct Answer: A
Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV.
Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes.
Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
Question 3 of 5
While taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer, the nurse learns that the patient is complaining of epigastric pain. What assessment finding would the nurse expect to note?
Correct Answer: A
Rationale: Melena is the passage of black, tarry stools due to the presence of blood in the gastrointestinal tract, usually originating from the upper digestive system. In the context of a Duodenal Ulcer, melena can occur as a result of bleeding in the duodenum or the upper part of the small intestine. This finding is significant as it indicates potential gastrointestinal bleeding, which is a common complication of duodenal ulcers. Nausea (
Choice
B) is a nonspecific symptom that may be present with various gastrointestinal conditions but is not specific to duodenal ulcers. Hernia (
Choice
C) involves the protrusion of an organ through the wall of the cavity that normally contains it and is not directly related to the symptoms of a duodenal ulcer. Hyperthermia (
Choice
D), which refers to an elevated body temperature, is not typically associated with duodenal ulcers unless there are severe complications present.
Question 4 of 5
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?
Correct Answer: C
Rationale: The correct answer is the patient's temperature of 100.8°F (38.2°
C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.
Question 5 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.