NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?
- A. Performing passive, light range-of-motion exercises on the hip as tolerated.
- B. Assess the patient's mental status for drowsiness or sleepiness.
- C. Assess the pedal pulse and capillary refill in the toes.
- D. Administer a stool softener as ordered.
Correct answer: B
Rationale: In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.
2. Which oxygen delivery system would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct answer: C
Rationale: The correct answer is the non-rebreather mask. This oxygen delivery system has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent the inhalation of room air but allow exhalation of air. When a tight seal is achieved around the mask, up to 100% of oxygen is available. Choice A, the Venturi mask, delivers precise oxygen concentrations but not as high as the non-rebreather mask. Choice B, the partial rebreather mask, allows the client to rebreathe some exhaled air, resulting in lower oxygen concentrations than the non-rebreather mask. Choice D, the simple face mask, delivers low to moderate oxygen concentrations and is not designed to provide the highest concentrations like the non-rebreather mask.
3. Which patient is at risk for developing oral candidiasis, a type of stomatitis?
- A. A 77-year-old woman in a long-term care facility taking an antibiotic
- B. A 35-year-old man who has had HIV for 6 years
- C. A 40-year-old man who is undergoing chemotherapy
- D. An 80-year-old woman with dentures
Correct answer: A
Rationale: The correct answer is a 77-year-old woman in a long-term care facility taking an antibiotic. This patient has multiple risk factors for developing oral candidiasis, including older age, being in a long-term care facility, and taking antibiotics. Candidiasis can be caused by long-term antibiotic therapy, immunosuppressive therapy (such as chemotherapy), older age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene. Choices B, C, and D are less likely to be at high risk for oral candidiasis compared to the correct answer.
4. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct answer: A
Rationale: Oculogyric crisis is a known side effect of antipsychotic medications like Haloperidol (Haldol) and is characterized by involuntary upward deviation of the eyes. This condition can be distressing to both the client and their family. Tardive dyskinesia (Choice B) is a different side effect characterized by repetitive, involuntary movements, especially of the face and tongue, which can occur with long-term antipsychotic use. Nystagmus (Choice C) is an involuntary eye movement that is rhythmic and can occur for various reasons but is not specific to Haloperidol use. Dysphagia (Choice D) refers to difficulty swallowing and is not typically associated with the use of Haloperidol.
5. Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct answer: D
Rationale: Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.
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