NCLEX-RN
NCLEX RN Practice Questions Quizlet
1. A patient's chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
- A. Vomiting
- B. Extreme Thirst
- C. Weight gain
- D. Acetone breath smell
Correct answer: C
Rationale: In acute ketoacidosis, a patient typically experiences rapid weight loss due to the body burning fat and muscle for energy in the absence of sufficient insulin. Therefore, weight gain would not be expected. Vomiting may occur due to the metabolic disturbances associated with ketoacidosis. Extreme thirst is a common symptom as the body tries to compensate for dehydration. Acetone breath smell is a classic sign of ketoacidosis as acetone is one of the ketones produced during this condition.
2. A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?
- A. Blood sugar check
- B. CT scan
- C. Blood cultures
- D. Arterial blood gases
Correct answer: C
Rationale: The most likely test to be performed first in this scenario is blood cultures. Blood cultures are crucial to investigate the fever and rash symptoms in an unconscious patient. This test is used to detect foreign invaders like bacteria, yeast, and other microorganisms in the blood, which could indicate a blood infection (bacteremia). A positive blood culture result confirms the presence of bacteria in the blood. A blood sugar check (choice A) may be important but is less likely to be the first test in this context. A CT scan (choice B) and arterial blood gases (choice D) are generally not the initial tests performed to investigate a fever and rash with altered mental status.
3. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?
- A. The tumor is less than 3 cm in size and requires no chemotherapy.
- B. The tumor did not extend beyond the kidney and was completely resected.
- C. The tumor extended beyond the kidney but was completely resected.
- D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct answer: C
Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.
4. A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
- A. Start a peripheral IV
- B. Initiate high-quality chest compressions
- C. Establish an airway
- D. Obtain the crash cart
Correct answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.
5. A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
- A. Blood sugar check
- B. CT scan
- C. Blood cultures
- D. Arterial blood gases
Correct answer: A
Rationale: In a 28-year-old male presenting with confusion, sweating, and pallor, the most likely cause is hypoglycemia, especially with no mention of trauma or infection. Therefore, the initial test to be performed should be a blood sugar check to rule out low blood sugar levels. Checking blood sugar levels is crucial in such a scenario as hypoglycemia can lead to altered mental status. A CT scan (choice B) is not typically the initial test for altered mental status without any focal neurological signs or head trauma. Blood cultures (choice C) are more relevant in cases suspected of infection, which is not a primary concern in this scenario. Arterial blood gases (choice D) may be considered later if there are concerns about respiratory status or acid-base disturbances, but in this case, checking the blood sugar level is the most immediate and appropriate action.
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