NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which patient poses the least infection risk to an immunosuppressed patient who had a liver transplant?
Correct Answer: C
Rationale: The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections.
Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.
Question 2 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.
Question 3 of 5
A client is in the post-anesthesia care unit (PACU) shivering despite being covered with several layers of blankets. What is the nurse's next action?
Correct Answer: C
Rationale: In the post-anesthesia care unit, clients may experience shivering or chills due to a drop in body temperature after surgery. Meperidine (Demerol) can be prescribed to alleviate shivering in cold clients. The prone position (lying face down) and deep breathing exercises are not interventions specifically indicated for addressing shivering due to low body temperature.
Therefore, administering meperidine as ordered is the most appropriate action to manage the client's shivering in this scenario.
Question 4 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 5 of 5
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.