NCLEX-RN
NCLEX RN Exam Review Answers
1. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?
- A. "I should be experiencing less blurriness in my central field of vision"
- B. "This medication won't help my vision at all, but will keep it from getting worse."
- C. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
- D. "This medication will help my eye restor intraocular fluid and increase intraocular pressure"
Correct answer: B
Rationale: Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.
2. The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?
- A. ''Has your child had any nausea or diarrhea?''
- B. ''Have you noticed any rashes on your child?''
- C. ''Did your child recently complain of a sore throat?''
- D. ''Did your child sustain any injuries to the kidney area?''
Correct answer: C
Rationale: The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.
3. A patient is suspected to have sustained a spinal cord injury. What best describes the overarching principles used to guide the care for this type of condition?
- A. Immobilize the cervical area to prevent further injury
- B. Monitor the patient's level of consciousness to prevent neurologic deterioration
- C. Help the patient with activities of daily living and provide emotional and physical support to help them adjust to their injury
- D. Facilitate tissue perfusion to the spinal cord while maintaining airway and breathing
Correct answer: D
Rationale: The correct answer is to facilitate tissue perfusion to the spinal cord while maintaining airway and breathing. In the acute phase of a spinal cord injury, ensuring proper tissue perfusion to the spinal cord is crucial to prevent further damage. Maintaining airway, breathing, and circulation is essential in guiding the overall care for a patient with a spinal cord injury. Choices A, B, and C, while important in certain aspects of care, are not the overarching principles that guide the immediate management of a suspected spinal cord injury.
4. When teaching the client with tuberculosis about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct answer: A
Rationale: The nurse should emphasize the importance of monitoring liver function tests in clients taking INH due to the risk of hepatocellular injury and hepatitis associated with this medication. Regular assessment of liver enzymes can help detect liver damage early. Monitoring kidney function, blood sugar levels, or cardiac enzymes is not specifically required for clients taking INH and tuberculosis treatment.
5. A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
- A. Intercostal retractions
- B. Kussmaul respirations
- C. Low oxygen saturation (SpO2)
- D. Decreased venous O2 pressure
Correct answer: B
Rationale: Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.
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