Exam Cram NCLEX RN Practice Questions

Exam Cram NCLEX RN Practice Questions Related

Review Exam Cram NCLEX RN Practice Questions related questions and content

A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31."? On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?

  • A. Continue the current plan without changes.
  • B. Remove this nursing diagnosis from the plan of care.
  • C. Write a new nursing diagnosis that better reflects the problem.
  • D. Revise the target date for outcome attainment and examine interventions.
Correct Answer: D

Rationale: The correct action for the nurse in this scenario is to revise the target date for outcome attainment and reevaluate interventions. The initial desired outcome was for the patient to sleep for a minimum of 5 hours nightly by October 31. Since the patient is currently sleeping an average of 4 hours nightly and taking a 2-hour afternoon nap, the goal has not been achieved. By extending the time frame for attaining the outcome, the patient may have more time to progress towards the desired sleep duration. Additionally, examining interventions is crucial to identify any changes or adjustments that may be necessary to help the patient achieve the desired outcome. Continuing the current plan without changes is not appropriate as the goal has not been met. Removing the nursing diagnosis from the plan of care should only be considered when the problem is resolved. Writing a new nursing diagnosis is not needed as the current diagnosis of Insomnia still accurately reflects the patient's condition.

You may also like to solve these questions

The physician has decided to perform a thoracentesis based on Mr. R's assessment. Which of the following actions from the nurse is most appropriate?

  • A. Instruct the client not to talk during the procedure
  • B. Assist the client to sit upright or slightly lean forward
  • C. Insert a 20-gauge needle just above the 4th intercostal space
  • D. Connect the needle to suction to remove fluid that has collected in the pleural space
Correct Answer: A

Rationale: The correct answer is to instruct the client not to talk during the procedure. This is important to prevent air from being drawn into the pleural space during the thoracentesis. Choice B is incorrect because the client should be sitting upright or slightly leaning forward during the procedure to facilitate access to the pleural space. Choice C is incorrect as the nurse should not perform the thoracentesis procedure, which involves inserting a needle into the pleural space - this is the physician's responsibility. Choice D is incorrect as connecting the needle to suction to remove fluid is not the appropriate procedure for a thoracentesis. Thoracentesis is typically done to remove fluid or air for diagnostic or therapeutic purposes, not to connect to suction to remove fluid that has collected in the pleural space.

An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?

  • A. Does the child have any food allergies?
  • B. What do the bowel movements look like?
  • C. Has the child eaten any food in the last 24 hours?
  • D. Can you describe the type of pain that the child is experiencing?
Correct Answer: D

Rationale: The correct answer is asking the parents to describe the type of pain the child is experiencing because a report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. This specific question helps in identifying the key symptom of intussusception. Choices A, B, and C are important aspects of a health history but are not specific to the diagnosis of intussusception. Food allergies, bowel movements, and recent food intake are relevant for a comprehensive assessment but do not directly relate to the specific symptoms of intussusception.

A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?

  • A. compound fracture of the fibula
  • B. a partial break in a long bone
  • C. fracture of the growth plate of the ulna near the wrist
  • D. Colles fracture of the tibia
Correct Answer: B

Rationale: A Greenstick Fracture is commonly found in children due to their bones being more flexible. This type of fracture occurs when a bone bends and partially breaks, resembling what happens when a green stick from a tree is bent in half. Therefore, the most accurate description of a Greenstick Fracture is 'a partial break in a long bone.' Choice A, 'compound fracture of the fibula,' is incorrect as a Greenstick Fracture is not a compound fracture. Choice C, 'fracture of the growth plate of the ulna near the wrist,' is incorrect as it describes a different type of fracture. Choice D, 'Colles fracture of the tibia,' is incorrect as it refers to a specific type of fracture in a different bone.

The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan?

  • A. Corn
  • B. Chicken
  • C. Oatmeal
  • D. Vitamin supplements
Correct Answer: C

Rationale: In celiac disease, individuals need to avoid gluten-containing foods like wheat, rye, barley, and oats. Oatmeal contains gluten unless it is specifically labeled as gluten-free. Corn and rice are safe alternatives for individuals with celiac disease as they do not contain gluten. Chicken is a naturally gluten-free protein source. While vitamin supplements may be necessary to address deficiencies due to malabsorption, oatmeal poses a risk of gluten exposure, making it an incorrect choice for a child with celiac disease.

Septic, anaphylactic, and neurogenic shock are all categorized as:

  • A. Hypovolemic shock
  • B. Cardiogenic shock
  • C. Distributive shock
  • D. Obstructive shock
Correct Answer: C

Rationale: Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.

Copyright © 2025 Nokea. All rights reserved.