NCLEX-RN
NCLEX RN Exam Review Answers
1. The nurse is caring for an infant with cryptorchidism. The nurse anticipates that the most likely diagnostic study to be prescribed would be the one that assesses which item?
- A. Babinski reflex
- B. DNA synthesis
- C. Urinary function
- D. Chromosomal analysis
Correct answer: C
Rationale: Cryptorchidism, also known as undescended testes, may be caused by hormonal deficiency, intrinsic testicular abnormality, or a structural problem. Diagnostic studies for cryptorchidism typically involve assessing urinary function because the kidneys and testes originate from the same embryonic tissue. The Babinski reflex is a test for neurological function and is not relevant to evaluating cryptorchidism. DNA synthesis and chromosomal analysis are not commonly used diagnostic tests for cryptorchidism, as they are unrelated to the disorder's etiology or presentation.
2. Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
- A. Teach the patient to avoid using over-the-counter expectorants.
- B. Assist the patient with chest physiotherapy and postural drainage.
- C. Notify the healthcare provider immediately regarding any bloody or foul-smelling sputum.
- D. Teach about the necessity of prolonged antibiotic therapy after discharge from the hospital.
Correct answer: D
Rationale: For a patient diagnosed with a lung abscess, the priority intervention is to educate them about the importance of prolonged antibiotic therapy post-hospital discharge. Long-term antibiotic treatment is crucial for eradicating the infecting organisms in a lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess as they can potentially spread the infection. While foul-smelling and bloody sputum are common in lung abscess, immediate notification to the healthcare provider is essential. Avoiding the use of over-the-counter expectorants is not necessary, as expectorants can be used to facilitate coughing and clearing of secretions in this condition.
3. A patient has a history of photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select one that doesn't apply
- A. Ciprofloxacin (Cipro)
- B. Sulfonamide
- C. Norfloxacin (Noroxin)
- D. Nitro-Dur patch
Correct answer: D
Rationale: Nitro-Dur patch is not associated with photosensitive reactions. It is used to prevent chest pain or angina, and common side effects include headache, lightheadedness, nausea, and flushing. Choices A, B, and C are known to cause photosensitive reactions. Ciprofloxacin (Cipro), Sulfonamides, and Norfloxacin (Noroxin) are drugs that are commonly associated with photosensitivity reactions. Patients taking these medications should be advised to avoid direct sunlight and use sun protection to prevent skin reactions.
4. 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.
5. When supporting the psychosocial needs of a client experiencing negative side effects associated with chemotherapy, which intervention is most appropriate?
- A. Read the client's discharge instructions well in advance of dismissal
- B. Provide medications to reduce nausea and vomiting
- C. Give simple instructions about self-care while in the hospital
- D. Determine the levels of support from significant others
Correct answer: D
Rationale: When a client is experiencing negative side effects associated with chemotherapy, addressing their psychosocial needs is crucial. One effective intervention is to determine the levels of support from significant others. This involves assessing the family, spouse, or friends who can provide help and support to the client when healthcare providers are not present. By identifying and organizing these resources, the nurse can help alleviate fears about the future, prepare caregivers for the client's needs, and facilitate a smoother transition for the client upon discharge. Reading discharge instructions, providing medications, or giving self-care instructions, although important, do not directly address the psychosocial needs of the client during this challenging time.
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