NCLEX-RN
NCLEX RN Actual Exam Test Bank
1. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
- A. Angina at rest
- B. Thrombus formation
- C. Dizziness
- D. Falling blood pressure
Correct answer: B
Rationale: Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.
2. Which bloodborne pathogen is the most virulent? (Choose the BEST answer.)
- A. HCV
- B. HPV
- C. HIV
- D. HBV
Correct answer: A
Rationale: The correct answer is HCV (Hepatitis C Virus). Hepatitis C is considered the most virulent bloodborne pathogen, being 100 times more virulent than Hepatitis B. HPV (Human Papillomavirus) is a sexually transmitted infection but is not a bloodborne pathogen. HIV (Human Immunodeficiency Virus) affects the immune system but is not as virulent as Hepatitis C in terms of bloodborne transmission. HBV (Hepatitis B Virus) is less virulent compared to HCV in the context of bloodborne transmission.
3. Penny Thornton has had a stroke, or CVA, and is having difficulty eating on her own. Soon, she will be getting some assistive devices for eating meals. Which healthcare worker will be providing Penny with these assistive devices?
- A. A physical therapist
- B. A speech therapist
- C. A social worker
- D. An occupational therapist
Correct answer: D
Rationale: An occupational therapist is the healthcare professional responsible for assessing the needs of individuals, like Penny, regarding assistive devices that aid them in their daily activities. In this case, assistive devices for eating, such as weighted plates and specialized utensils, are crucial for helping Penny regain independence in feeding herself. Physical therapists focus more on mobility and movement, speech therapists on communication and swallowing disorders, and social workers on providing emotional and social support. Therefore, the correct choice is the occupational therapist as they specialize in activities of daily living and promoting independence.
4. While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am, 2 pm, and 6 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: C
Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
5. A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?
- A. These readings are a normal response and attributable to changes in the patient's position.
- B. The change in blood pressure readings is called orthostatic hypotension.
- C. The blood pressure reading in the lying position is within normal limits.
- D. The change in blood pressure readings is considered within normal limits for the patient's age.
Correct answer: B
Rationale: The correct answer is, 'The change in blood pressure readings is called orthostatic hypotension.' Orthostatic hypotension is defined as a drop in systolic pressure of �20 mm Hg or �10 mm Hg drop in diastolic pressure that occurs with a quick change to a standing position. This condition is common in individuals on prolonged bed rest, older adults, those with hypovolemia, or taking specific medications. The blood pressure readings provided in the question (150/90 mm Hg lying, 130/80 mm Hg sitting, and 100/60 mm Hg standing) demonstrate a significant change in blood pressure with position changes, which is indicative of orthostatic hypotension. Choices A, C, and D are incorrect because the readings do not indicate a normal response or blood pressure within normal limits for the patient's age; rather, they suggest the presence of orthostatic hypotension.
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