NCLEX-RN
NCLEX RN Exam Review Answers
1. When assessing a patient being treated for Parkinson's Disease with classic symptoms, the nurse expects to note which assessment finding?
- A. Tremors
- B. Low Urine Output
- C. Exaggerated arm movements
- D. Risk for Falls
Correct answer: A
Rationale: When assessing a patient with Parkinson's Disease, the nurse should expect to note tremors as one of the cardinal signs of the condition. The classic symptoms of Parkinson's Disease include tremors, rigidity, bradykinesia (slow movements), and postural instability. Therefore, choices B, C, and D are incorrect. Low urine output is not a typical assessment finding associated with Parkinson's Disease. Exaggerated arm movements are not characteristic of the usual motor symptoms seen in Parkinson's Disease. While patients with Parkinson's Disease are at an increased risk for falls due to balance and coordination issues, 'Risk for Falls' is not an assessment finding but rather a potential nursing diagnosis based on the assessment findings.
2. What is the most common complication of chest wall injury?
- A. Hemothorax
- B. Atelectasis
- C. Pneumonia
- D. Pneumothorax
Correct answer: C
Rationale: Pneumonia is the most common complication of chest wall injury. Chest wall trauma can lead to impaired lung function, making patients more susceptible to pneumonia due to reduced ability to clear secretions and impaired breathing. While hemothorax and pneumothorax are potential complications of chest wall injury, pneumonia is more commonly encountered. Atelectasis, although a common pulmonary complication, is not typically the most common complication seen in chest wall injuries.
3. The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?
- A. ''I will use a short nipple on the bottle.''
- B. ''I should avoid using straws for drinking.''
- C. ''I can give my child the pacifier in 2 weeks.''
- D. ''I may give my baby food mixed with water.''
Correct answer: B
Rationale: The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.
4. A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?
- A. Try to reposition the hearing aid
- B. Change the batteries
- C. Remove the device and have it cleaned
- D. Notify the physician that the hearing aid is not working
Correct answer: A
Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.
5. After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?
- A. Urinary incontinence
- B. Impaired tissue integrity
- C. Inability to suck and swallow
- D. Lack of knowledge about the disease (parents)
Correct answer: B
Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.
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