NCLEX-RN
NCLEX RN Exam Questions
1. Which patient poses the least infection risk to an immunosuppressed patient who had a liver transplant?
- A. The patient with chronic pancreatitis
- B. The patient currently infected with a respiratory virus
- C. The patient with a healing leg wound
- D. The patient with a urinary tract infection
Correct answer: C
Rationale: The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections. Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.
2. Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?
- A. Strip the tubing to remove clots by milking the tubing back toward the client
- B. Empty the drain when the amount of fluid reaches 25 cc
- C. Strip the tubing to remove clots by milking the tubing away from the client
- D. Maintain the level of the drain above the client's incision
Correct answer: C
Rationale: A Jackson-Pratt drain is a type of active wound drain that may be placed following a surgical procedure. This drain actively draws excess blood and fluid out of the wound. If clots develop within the tubing, the nurse should strip the tubing by milking it in a direction away from the client. This action helps to ensure the drain remains patent and effective. Option A is incorrect because the tubing should be milked away from the client, not towards. Option B is incorrect as the drain should be emptied based on the healthcare provider's orders, not at a fixed volume. Option D is incorrect because the level of the drain should be below the level of the incision to allow drainage by gravity.
3. The healthcare provider is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory?
- A. Name the year. What season is this? (pause for answer after each question)
- B. Subtract 7 from 100 and then subtract 7 from that. (pause for answer) Now continue to subtract 7 from the new number.
- C. I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen.
- D. What is this on my wrist? (point to your watch) Then ask, What is the purpose of it?
Correct answer: B
Rationale: The correct answer is to ask the client to perform a calculation that involves working memory and processing skills. This question not only assesses the recent memory but also evaluates attention and executive functioning. The choice 'I am going to say the names of three things, and I want you to repeat them after me: blue, ball, pen' assesses immediate recall rather than recent memory. Asking about the current year or season tests orientation rather than recent memory. Inquiring about the watch and its purpose assesses comprehension and judgment rather than recent memory.
4. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
- A. Polyphagia
- B. Dehydration
- C. Bedwetting
- D. Weight loss
Correct answer: C
Rationale: The correct answer is 'Bedwetting.' One of the initial symptoms of type 1 diabetes in children is bedwetting. Parents are likely to notice bedwetting in a school-age child, prompting them to seek evaluation. Polyphagia (excessive hunger) and weight loss are also common symptoms of diabetes but may not be as readily noticeable to parents compared to bedwetting. Dehydration is a consequence of diabetes rather than an early symptom that would prompt parents for evaluation.
5. A patient with stage I nonsmall cell lung cancer expresses a preference for chemotherapy over surgery. Which response by the nurse is most appropriate?
- A. Are you concerned about the potential pain from surgery?
- B. Have you had negative experiences with previous surgeries?
- C. Surgery is the recommended treatment for stage I lung cancer.
- D. Tell me about your understanding of the different available treatments.
Correct answer: D
Rationale: The most appropriate response by the nurse in this situation is to gather more information about the patient's concerns and preferences. By asking the patient to share their understanding of the available treatments, the nurse encourages open communication and gains insight into the patient's knowledge and preferences. Option A focuses solely on pain, which may not be the patient's primary concern. Option B assumes negative experiences without exploring the patient's current thoughts. Option C, stating that surgery is the recommended treatment, dismisses the patient's preference and does not address their concerns. Chemotherapy is not the primary treatment for nonsmall cell lung cancer; it may be used for nonresectable tumors or as adjuvant therapy to surgery, making it crucial for the nurse to explore the patient's treatment preferences and understanding.
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