NCLEX RN· Full Length · NCLEX-RN Exam
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
The nurse is caring for a client with a history of atrial fibrillation. Which finding requires immediate intervention?
Expert Explanatory Rationale
Correct Answer: Dizziness and syncope
Dizziness and syncope in atrial fibrillation suggest hemodynamic instability, possibly from rapid ventricular response, requiring immediate intervention. Mild tachycardia, normal BP, and saturation are less urgent.
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is 'rule out hepatitis.' Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease?
Expert Explanatory Rationale
Correct Answer: Oncology nurses
Oncology nurses are at high risk due to exposure to invasive procedures and potential sources of infection, unlike the other groups listed.
A common complaint of the client with an abdominal aortic aneurysm is:
Expert Explanatory Rationale
Correct Answer: Pulsations in the periumbilical area
A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
Expert Explanatory Rationale
Correct Answer: Vertigo
Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.
The nurse is caring for a client with a history of glaucoma. The nurse should expect the client to have:
Expert Explanatory Rationale
Correct Answer: Peripheral vision loss
Glaucoma causes increased intraocular pressure, damaging the optic nerve and leading to peripheral vision loss, a hallmark symptom.
A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of:
Expert Explanatory Rationale
Correct Answer: Flight of ideas
Rapidly moving from one topic to another without following any logical sequence is called flight of ideas, characteristic of manic behavior.
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
Expert Explanatory Rationale
Correct Answer: Cry
This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
Expert Explanatory Rationale
Correct Answer: Maintenance of the BP at 90 mmHg or greater
Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature (B) is important but secondary, low hematocrit (C) is not a goal, and 300 mL/hr urine output (D) is excessive.
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Expert Explanatory Rationale
Correct Answer: Significant head lag when raised to a sitting position
Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
Expert Explanatory Rationale
Correct Answer: Assess the client for a distended bladder.
Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (B) is priority. Notifying the physician (A), oxygen (C), or fluids (D) is secondary.
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