NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
Correct Answer: B
Rationale: The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.
Question 2 of 5
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
Correct Answer: A
Rationale: The priority nursing diagnosis for a patient experiencing a migraine headache is 'Acute pain related to biologic and chemical factors.' Migraine headaches are characterized by severe throbbing pain, often accompanied by sensitivity to light and sound. Addressing the acute pain is crucial to improve the patient's comfort and quality of life.
Choices B, C, and D are not the priority nursing diagnoses for a patient with a migraine headache. Anxiety, hopelessness, and risk for side effects may not be as urgent as managing the acute pain associated with a migraine.
Question 3 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 4 of 5
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
Correct Answer: B
Rationale: The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
Question 5 of 5
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
Correct Answer: C
Rationale: Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.