NCLEX-RN
Exam Cram NCLEX RN Practice Questions
1. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
- A. We will encourage our child to cough every few hours on a daily basis.
- B. We will make sure that our child participates in physical activity every day.
- C. We will provide comfort measures to reduce any crying periods by our child.
- D. We will be sure to give our child a Fleet enema every day to prevent constipation.
Correct answer: C
Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
2. A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?
- A. The life span of RBC is 45 days
- B. The life span of RBC is 60 days
- C. The life span of RBC is 90 days
- D. The life span of RBC is 120 days
Correct answer: D
Rationale: The correct answer is that red blood cells have a lifespan of 120 days in the body. This allows for efficient oxygen transport throughout the circulatory system. Choices A, B, and C are incorrect because the lifespan of red blood cells is actually 120 days. Understanding the lifespan of red blood cells is crucial in assessing various conditions related to blood cell production and turnover.
3. The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?
- A. Stroke volume
- B. Cardiac output
- C. Venous pressure
- D. Left ventricular functioning
Correct answer: D
Rationale: The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.
4. The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking cigarettes for 30 years, the nurse expects to note which assessment finding?
- A. Increase in Forced Vital Capacity (FVC)
- B. A widened chest cavity
- C. Clubbed fingers
- D. An increased risk of cardiac failure
Correct answer: C
Rationale: 1. Increase in Forced Vital Capacity (FVC): Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Therefore, this choice is incorrect. 2. A widened chest cavity: A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Hence, a narrowed chest cavity is not an expected finding. 3. Clubbed fingers - CORRECT: Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels, which is commonly seen in patients with chronic respiratory conditions like Emphysema and Chronic Bronchitis. 4. An increased risk of cardiac failure: Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding, making it an incorrect choice.
5. The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?
- A. Restrict fluids as prescribed.
- B. Care for the arteriovenous fistula.
- C. Encourage foods high in potassium.
- D. Administer analgesics as prescribed.
Correct answer: A
Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.
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