NCLEX RN Exam Questions
Question 1 of 5.
A client had a cardiac catheterization with angiography and thrombolytic therapy with streptokinase. The nurse should initiate which of the following interventions immediately after he returns to his room?
A. Place him on NPO restriction for 4 hours.
B. Monitor the catheterization site every 15 minutes.
C. Place him in a high Fowler position.
D. Ambulate him to the bathroom to void.
Explanation: A contrast dye, iodine, is used in this procedure. This dye is nephrotoxic. The client must be encouraged to drink plenty of liquids to assist the kidneys in eliminating the dye. Streptokinase activates plasminogen, dissolving fibrin deposits. To prevent bleeding, pressure is applied at the insertion site. The client is assessed for both internal and external bleeding. The extremity used for the insertion site must be kept straight and be immobilized because of the potential for bleeding. The client is kept on bed rest for 8-12 hours following the procedure because of the potential for bleeding.
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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