NCLEX RN Exam Questions
Question 1 of 5.
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
A. Associated symptoms of indigestion and nausea
B. Restlessness and apprehensiveness
C. Inability to tolerate assessment session with the admitting nurse
D. History of hypertension treated with pharmacological therapy
Explanation: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 2 of 5.
A client is diagnosed with stage II Hodgkin's lymphoma. The nurse recognizes that the client has involvement:
A. In a single lymph node or single site
B. In more than one node or single organ on the same side of the diaphragm
C. In lymph nodes on both sides of the diaphragm
D. In disseminated organs and tissues
Explanation: Stage II Hodgkin's lymphoma involves two or more lymph nodes or a single organ on the same side of the diaphragm, per the Ann Arbor staging system.
Question 3 of 5.
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
A. Drainage on the surgical dressing
B. Complaints of neck pain
C. Bleeding from the mouth
D. Swelling in the posterior neck
Explanation: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, making it a priority assessment post-cervical discectomy.
Question 4 of 5.
Which of the following combinations of foods is appropriate for an eight-month-old infant?
A. Cocoa-flavored cereal, orange juice, and strained meat
B. Graham crackers, strained prunes, and pudding
C. Rice cereal, bananas, and strained carrots
D. Mashed potatoes, strained beets, and whole milk
Explanation: Rice cereal, bananas, and strained carrots are developmentally appropriate, easily digestible foods for an eight-month-old, unlike the other options, which include choking hazards or inappropriate items like whole milk.
Question 5 of 5.
A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:
A. Serum glucose levels
B. Liver enzymes
C. Pancreatic enzymes
D. Plasma protein levels
Explanation: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is characterized by elevated liver enzymes, reflecting liver dysfunction.
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