NCLEX-RN
NCLEX RN Exam Questions
1. A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
- A. Schedule the patient for HCV genotype testing.
- B. Administer the HCV vaccine and immune globulin.
- C. Teach the patient about ribavirin (Rebetol) treatment.
- D. Explain that the infection will resolve over a few months.
Correct answer: A
Rationale: The correct action by the nurse is to schedule the patient for HCV genotype testing. Genotyping of HCV is crucial in determining the appropriate treatment regimen and guiding therapy decisions. Most patients with acute HCV infection progress to the chronic stage, so it is incorrect to inform the patient that the infection will resolve in a few months. There is no vaccine or immune globulin available for HCV, and ribavirin (Rebetol) is typically used for chronic HCV infection. Therefore, the nurse should prioritize genotyping to assist in treatment planning.
2. During a physical exam, a healthcare professional assisting a client suspected of having meningitis bends the client's leg at the hip to a 90-degree angle. When attempting to extend the leg at the knee, the client experiences severe pain. What type of test is being performed?
- A. Brudzinski's sign
- B. Romberg's sign
- C. Kernig's sign
- D. Babinski's sign
Correct answer: C
Rationale: The healthcare professional is performing Kernig's sign, a test for meningeal irritation often seen in meningitis cases. Kernig's sign involves bending the client's leg at a 90-degree angle at the hip and then attempting to extend the leg at the knee. Severe pain during this maneuver indicates a positive Kernig's sign, suggesting irritation of the meningeal membranes. Brudzinski's sign involves flexing the neck causing involuntary flexion of the hips and knees; Romberg's sign assesses balance and proprioception; Babinski's sign checks for abnormal reflexes in the foot.
3. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?
- A. Manage secretions by providing suction on a regular basis
- B. Cleanse the site daily with a mixture of povidone-iodine and water
- C. Avoid using tube ties to secure the tube
- D. None of the above
Correct answer: A
Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation. Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine. Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability. Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.
4. During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
- A. "I have constant blurred vision."?
- B. "I can't see on my left side."?
- C. "I have to turn my head to see my room."?
- D. "I have specks floating in my eyes."?
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.
5. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct answer: A
Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.
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