NCLEX-RN
NCLEX RN Exam Questions
1. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:
- A. Urinary output of 30 ml per hour
- B. No complaints of thirst
- C. Increased hematocrit
- D. Good skin turgor around burn
Correct answer: A
Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces.
2. 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.
3. What should the nurse in the emergency department do first for a new patient who is vomiting blood?
- A. Insert a large-gauge IV catheter.
- B. Draw blood for coagulation studies.
- C. Check blood pressure (BP), heart rate, and respirations.
- D. Place the patient in the supine position.
Correct answer: C
Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.
4. 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?
- A. Restrict daily dietary protein intake.
- B. Reposition the patient every 4 hours.
- C. Place the patient on a pressure-relieving mattress.
- D. Perform passive range of motion daily.
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.
5. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?
- A. Bowel sounds are present.
- B. Grey Turner sign resolves.
- C. Electrolyte levels are normal.
- D. Abdominal pain is decreased.
Correct answer: D
Rationale: The correct answer is 'Abdominal pain is decreased.' In a patient with acute pancreatitis, the goal of using an NG tube for suction and keeping the patient NPO is to decrease the release of pancreatic enzymes and alleviate pain. Therefore, a decrease in abdominal pain would indicate the effectiveness of these therapies. Bowel sounds being present do not necessarily indicate treatment effectiveness, as they can still be present even if the therapies are not fully effective. Normal electrolyte levels are important but do not directly reflect the efficacy of NG suction and NPO status. The resolution of Grey Turner sign, a bruising over the flanks associated with pancreatitis, is a late and non-specific finding and waiting for it to resolve is not a reliable indicator of treatment effectiveness.
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