NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
- A. The client complains of discomfort at the IV insertion site
- B. The client states 'I just can't get relief from my pain.'
- C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
- D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Correct answer: C
Rationale: The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.
2. A patient has come into the emergency room after an injury at work in which their upper body was pinned between two pieces of equipment. The nurse notes bruising in the upper abdomen and chest. The patient is complaining of sharp chest pain, having difficulty breathing, and their trachea is deviated to the left side. Which of the following conditions are these symptoms most closely associated with?
- A. Left-sided pneumothorax
- B. Pleural effusion
- C. Atelectasis
- D. Right-sided pneumothorax
Correct answer: D
Rationale: The patient is most likely suffering from a right-sided pneumothorax. Symptoms of a pneumothorax include sharp chest pain, difficulties with breathing, decreased vocal fremitus, absent breath sounds, and tracheal shift to the opposite of the affected side. In this case, the patient's trachea is deviated to the left side, indicating a right-sided pneumothorax. Choices A, B, and C can be eliminated as they do not present with the specific symptoms described in the scenario. Left-sided pneumothorax would not cause tracheal deviation to the left side. Pleural effusion typically presents with dull chest pain and decreased breath sounds, not sharp chest pain and tracheal deviation. Atelectasis would not cause tracheal deviation and is more associated with lung collapse rather than air accumulation in the pleural space.
3. The patient in the emergency room has a history of alprazolam (Xanax) abuse and abruptly stopped taking Xanax about 24 hours ago. He presents with visible tremors, pacing, fear, impaired concentration, and memory. Which intervention takes priority?
- A. Have the patient lie down on a stretcher with bed rails raised
- B. Offer the patient a cup of water and a small amount of food
- C. Reassure the patient about his well-being
- D. Inform the physician about the patient's Xanax withdrawal
Correct answer: A
Rationale: The 1-4 day period after Xanax withdrawal is critical as it poses the highest risk of life-threatening seizures. Alprazolam is a benzodiazepine, and sudden cessation can lead to severe withdrawal symptoms. The patient's visible tremors, fear, pacing, and cognitive impairment indicate a state of heightened distress and potential seizure risk. Placing the patient on a stretcher with raised bed rails is essential for seizure precautions, ensuring safety and preventing injury during a potential seizure. Offering water and food, reassuring the patient, or informing the physician about Xanax withdrawal are not immediate priorities compared to managing the risk of seizures in this high-risk situation.
4. After repair of an inguinal hernia, the infant is being cared for. Which assessment finding indicates that the surgical repair was effective?
- A. A clean, dry incision
- B. Abdominal distension
- C. An adequate flow of urine
- D. Absence of inguinal swelling with crying
Correct answer: D
Rationale: The absence of inguinal swelling when the infant cries or strains indicates that the surgical repair of the inguinal hernia was effective. Inguinal swelling typically occurs with crying or straining in cases of this condition. A clean, dry incision signifies the absence of wound infection post-surgery but does not directly indicate the effectiveness of the hernia repair. Abdominal distension suggests a gastrointestinal issue unrelated to the hernia repair. An adequate flow of urine is not specific to evaluating the success of inguinal hernia repair.
5. What is the most appropriate suggestion regarding the diet for an 18-month-old child experiencing mild diarrhea and 'mushy' stools, but tolerating fluids and solid foods?
- A. Applesauce, bananas, wheat toast
- B. Mashed potatoes with baked chicken
- C. Gelatin, strained cabbage, and custard
- D. Fluids only until the 'mushy' stools stop
Correct answer: B
Rationale: For a child with mild diarrhea who is tolerating fluids and solid foods, the most appropriate diet suggestion would be to continue feeding a normal diet to prevent dehydration, reduce stool frequency and volume, and hasten recovery. Foods that are well tolerated during diarrhea include bland but nutritional options like complex carbohydrates (rice, wheat, potatoes, cereals), yogurt with live cultures, cooked vegetables, and lean meats. Mashed potatoes with baked chicken provide a balance of nutrients and are easy on the digestive system. Options A and C contain foods that may worsen diarrhea; applesauce and gelatin can be high in sugars which can exacerbate diarrhea, and cabbage may be hard to digest for some individuals. Option D of offering fluids only can affect the child's nutritional status by not providing enough essential nutrients during the recovery period.
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