Example NCLEX RN Question 2019 / 2020 / 2021 31th Edition (Adult Health & Child Health)

Example NCLEX RN Question 2019 / 2020 / 2021 31th Edition

1. A nurse is caring for a client with osteoarthritis. The nurse monitors the client knowing that which of the following is a clinical manifestation associated with the disorder?

A. Pain that increases with activity and is relieved by rest
B. An elevated platelet count
C. Symmetrical joint discomfort
D. Elevated antinuclear antibody levels

Answer: A. Pain that increases with activity and is relieved by rest

Rationale: The stiffness and joint pain that occur in osteoarthritis increase with activity and are relieved with rest. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Unlike rheumatoid arthritis, joint involvement is usually not symmetrical. Elevated white blood cell counts, platelet counts, and antinuclear antibodies occur in rheumatoid arthritis.

Test-Taking Strategy: Knowledge regarding the differences between osteoarthritis and rheumatoid arthritis is required to answer this question. Remember, the stiffness and joint pain that occur in osteoarthritis increase with activity and are relieved with rest. Review these differences if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Musculoskeletal
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders,pp. 581.

2. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric (NG) tube. The nurse plans to:

A. Ask the registered nurse to notify the physician immediately
B. Continue to monitor the drainage
C. Measure abdominal girth
D. Irrigate the NG tube

Answer: B. Continue to monitor the drainage

Rationale: Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively and then changes to brown-tinged, and then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. There is no need to notify the physician at this time. Measuring abdominal girth is performed to detect the development of distension. Following gastrectomy, a NG tube should not be irrigated.

Test-Taking Strategy: Use the process of elimination and note the key words immediate postoperative period. Recalling that bloody drainage is expected in this time period will direct you to option B. If you had difficulty with this question, review the postoperative expected findings following gastrectomy.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Oncology
Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, pp. 746-747.

3. A nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which data documented in the medical history are an unassociated risk factor of this type of cancer?

A. A history of inflammatory bowel disease
B. Family history of colon cancer
C. Regular consumption of a high-fiber diet
D. Regular consumption of a diet high in fats and carbohydrates

Answer: C. Regular consumption of a high-fiber diet

Rationale: Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10-years duration.

Test-Taking Strategy: Use the process of elimination and note the key word unassociated. Eliminate options 1 and 2 because they are similar and directly relate to the issue of colorectal cancer. From the remaining options, recalling that a high-fiber diet is recommended as a preventative measure will direct you to option C. Review the risk factors associated with colorectal cancer if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Oncology
Reference: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 705.

4. A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding?

A. Severely depressed fontanels
B. Slightly dry mucous membranes
C. Pale skin color
D. Oliguria

Answer: D. Oliguria

Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be very dry, the skin color would be dusky, and oliguria would be present. Options 2 and 3 describe mild dehydration. In mild dehydration, urine output would be decreased but oliguria would not be present. Option 1 describes severe dehydration.

Test-Taking Strategy: Note the key word moderately. This key word will assist in eliminating options 1, 2, and C. Review the manifestations related to mild, moderate, and severe dehydration if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 84.

5. A physician orders intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest priority item before administration of the potassium?

A. Temperature
B. Blood pressure
C. Weight
D. Urine output

Answer: D. Urine output

Rationale: The priority assessment would be to check the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. Although options 1, 2, and 3 may be a component of the data collected, they are not specifically related to the administration of this medication.

Test-Taking Strategy: Knowledge regarding the effects of potassium on various organ systems is required to answer the question. Recalling that the kidneys play a key role in the excretion and reabsorption of potassium will direct you to option D. Review this medication if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 158.

Source : NCLEX example quiz and answer

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