NCLEX RN Exam Questions

NCLEX RN Exam Questions Related

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A 30-year-old woman is experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?

  • A. Initiate cardiopulmonary resuscitation
  • B. Check for a pulse
  • C. Ask the woman if she carries an emergency medical kit
  • D. Stay with the woman until help comes
Correct Answer: C

Rationale: In a situation where a patient is experiencing anaphylaxis, it is crucial to act swiftly. Asking the woman if she carries an emergency medical kit is the most appropriate initial intervention. Many individuals with a history of anaphylaxis carry epinephrine auto-injectors, such as epi-pens, which can be life-saving in such situations. Initiating cardiopulmonary resuscitation (CPR) is not indicated as the patient is breathing but short of breath, and CPR is not the first-line intervention for anaphylaxis. Checking for a pulse, though important, is not the initial priority in managing anaphylaxis. Staying with the woman until help arrives is essential for providing support and monitoring her condition, but confirming the availability of an emergency medical kit takes precedence to promptly address the anaphylactic reaction.

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A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?

  • A. Hemoglobin of 11 g/dl
  • B. Platelet count of 150,000
  • C. INR of 2.5
  • D. Potassium of 2.7 mEq/L
Correct Answer: D

Rationale: The critical lab result that should be reported to the physician immediately in this case is the potassium level of 2.7 mEq/L. A potassium imbalance, especially in a patient with a history of dysrhythmia like atrial fibrillation, can be life-threatening and lead to cardiac distress. Low potassium levels (hypokalemia) can predispose the patient to dangerous arrhythmias, including worsening atrial fibrillation. Hemoglobin of 11 g/dl, platelet count of 150,000, and an INR of 2.5 are within acceptable ranges and not as immediately concerning as a low potassium level in this clinical context.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?

  • A. Nausea and vomiting
  • B. Hypotonic bowel sounds
  • C. Abdominal tenderness and guarding
  • D. Muscle twitching and finger numbness
Correct Answer: D

Rationale: The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.

To palpate the liver during a head-to-toe physical assessment, the nurse should

  • A. put pressure on the biopsy site using a sandbag
  • B. elevate the head of the bed to facilitate breathing
  • C. place the patient on the right side with the bed flat
  • D. check the patient's post-biopsy coagulation studies
Correct Answer: C

Rationale: To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.

A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

  • A. Back Pain
  • B. Fever and Chills
  • C. Risk for Bleeding
  • D. Dizziness
Correct Answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

What should the nurse in the emergency department do first for a new patient who is vomiting blood?

  • A. Insert a large-gauge IV catheter.
  • B. Draw blood for coagulation studies.
  • C. Check blood pressure (BP), heart rate, and respirations.
  • D. Place the patient in the supine position.
Correct Answer: C

Rationale: The nurse's initial action should focus on assessing the patient's hemodynamic status by checking vital signs like blood pressure, heart rate, and respirations. This assessment will help determine the patient's immediate needs and guide further interventions. Drawing blood for coagulation studies and inserting an IV catheter are important steps, but they can follow the initial assessment of vital signs. Placing the patient in the supine position can be risky without first assessing the patient's vital signs, as aspiration is a concern. Therefore, assessing vital signs is the priority to ensure appropriate and timely care for the patient.

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