NCLEX RN· Full Length · NCLEX RN Practice Questions Quizlet
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Showing all 10 practice questions with expert explanatory rationales.
The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?
Expert Explanatory Rationale
Correct Answer: LDH and CK MB
CK-MB and LDH are specific to cardiac muscle damage, with CK-MB being particularly indicative of myocardial infarction due to its cardiac specificity.
The nurse is caring for a client following a transphenoidal hypophysectomy. Post-operatively, the nurse should:
Expert Explanatory Rationale
Correct Answer: Check the nasal dressing for the “halo signâ€Â
The halo sign on the nasal dressing indicates cerebrospinal fluid leakage, a critical post-operative complication.
A pregnant woman undergoes a 40-minute nonstress test for evaluation of the fetal heart rate (FHR) and accelerations. Which of the following test results is normal (reactive)?
Expert Explanatory Rationale
Correct Answer: No accelerations of the FHR.
A reactive nonstress test requires at least two accelerations of FHR by 15 bpm for 15 seconds within 20-40 minutes. No accelerations (C) is considered normal (reactive) if other criteria are met, but typically, accelerations are expected. Options A, B, D do not meet standard reactive criteria.
A nursing assistant assigned to care for a client receiving linear accelerator radium therapy for laryngeal cancer states, 'I don't want to be assigned to that radioactive patient.' The best response by the nurse is to:
Expert Explanatory Rationale
Correct Answer: Tell the nursing assistant that the client is not radioactive
Linear accelerator therapy delivers external radiation, so the client is not radioactive and poses no risk to staff.
A client has been diagnosed with pernicious anemia. What breakfast should the nurse suggest to increase dietary B12?
Expert Explanatory Rationale
Correct Answer: scrambled eggs, beef sausage patty, milk
Pernicious anemia requires dietary B12 (found in eggs, meat, milk). Other options lack significant B12.
A mother brings in her 9-month-old son for a routine checkup. She asks the nurse what developmental milestones to expect by 12 months of age. All of the following are correct responses by the nurse EXCEPT
Expert Explanatory Rationale
Correct Answer: Your son should be able to point to an object when named.'
By 12 months, infants can imitate gestures, hold a bottle, and respond to their name. Pointing to a named object typically develops closer to 18 months.
A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:
Expert Explanatory Rationale
Correct Answer: Platelet count
Platelet count is the primary indicator of treatment response in autoimmune thrombocytopenic purpura, as the condition is characterized by low platelets.
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
Expert Explanatory Rationale
Correct Answer: Phlebostatic axis
The phlebostatic axis (4th intercostal space, mid-axillary line) is the standard reference point for accurate central venous pressure measurement.
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
Expert Explanatory Rationale
Correct Answer: Providing a supportive environment
A supportive environment fosters trust and safety, critical for a client with PTSD to begin processing trauma.
Nutrients per serving: [Table provided]. Which of the snacksâ€â€lunch meat, peanuts, cheese, or appleâ€â€has the lowest number of calories per serving?
Expert Explanatory Rationale
Correct Answer: Apple
Calories: Lunch meat = (6X 9) + (1X 4) + (7X 4) = 86; Peanuts = (14X 9) + (5X 4) + (7X 4) = 174; Cheese = (9X 9) + (1X 4) + (7X 4) = 113; Apple = (0.3X 9) + (25X 4) + (0.5X 4) = 104.7. Apple (D) has the lowest at ~105 calories.
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