NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 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.
Question 2 of 5
Which of the following types of dressing changes works as a form of wound debridement?
Correct Answer: D
Rationale: The correct answer is 'Wet to dry dressing.' Wet to dry dressing is a method of wound debridement that involves applying sterile soaked gauze to the wound, allowing it to dry and stick to the wound. When the dressing is removed, it pulls away drainage and debris, aiding in wound debridement.
Choice A, 'Dry dressing,' does not actively assist in debridement as it does not collect or remove debris from the wound.
Choice B, 'Transparent dressing,' is primarily used for maintaining a moist environment and wound observation, not for debridement.
Choice C, 'Composite dressing,' combines multiple layers for different wound care purposes but is not specifically designed for debridement like wet to dry dressing.
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
A child has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?
Correct Answer: C
Rationale: The correct answer is that nonsteroidal anti-inflammatory drugs are the first choice in treatment for juvenile idiopathic arthritis (formerly known as juvenile rheumatoid arthritis). NSAIDs are important as a first-line treatment and typically require 3-4 weeks for the therapeutic anti-inflammatory effects to be realized.
Choice A is incorrect as early treatment can improve outcomes and prevent joint deformities.
Choice B is incorrect as juvenile idiopathic arthritis does not necessarily progress to adult rheumatoid arthritis.
Choice D is incorrect as physical activity should be encouraged in children with arthritis to maintain joint mobility and overall health.
Question 5 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.