NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct answer: C
Rationale: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
2. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
- A. Rice
- B. Oatmeal
- C. Rye toast
- D. White bread
Correct answer: A
Rationale: In celiac disease, individuals are intolerant to gluten found in wheat, barley, rye, and oats. Therefore, it is crucial to eliminate these grains from the diet. Rice, corn, or millet are safe alternatives for individuals with celiac disease. Oatmeal is generally avoided unless specifically labeled as gluten-free due to possible cross-contamination. Rye toast and white bread contain gluten and should be avoided in celiac disease. Vitamin supplements may also be necessary to address deficiencies caused by dietary restrictions.
3. A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?
- A. Abdominal distention
- B. A bruit near the epigastric area
- C. 3 episodes of vomiting in the last hour
- D. Blood pressure of 160/90
Correct answer: B
Rationale: A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.
4. The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
- A. Neurotoxicity
- B. Hepatomegaly
- C. Nephrotoxicity
- D. Ototoxicity
Correct answer: C
Rationale: The correct answer is nephrotoxicity. Calcium disodium edetate, used in chelation therapy for lead poisoning, can lead to kidney toxicity. This is an important side effect to monitor in patients undergoing this treatment. Choices A, B, and D are incorrect. Neurotoxicity, hepatomegaly, and ototoxicity are not typically associated with calcium disodium edetate therapy for lead poisoning.
5. A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?
- A. Fear
- B. Helplessness
- C. Self-blame
- D. Rejection
Correct answer: C
Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.
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