The NCLEX exam is a crucial step in becoming a licensed nurse. To succeed in this exam, it is essential to have a solid understanding of common NCLEX questions and their corresponding answers. In this comprehensive review, we will explore some of the most frequently asked NCLEX questions and provide detailed explanations for the correct answers. By understanding the rationale behind each choice, students can enhance their critical thinking skills and improve their chances of success on the exam.
1. Question: What is the priority nursing intervention for a client experiencing chest pain?
Answer: The priority nursing intervention for a client experiencing chest pain is to assess and monitor the client's vital signs, administer oxygen if necessary, and promptly notify the healthcare provider. Chest pain can be a sign of a life-threatening condition, such as a myocardial infarction, and requires immediate attention.
Rationale: Assessing vital signs helps determine the severity of the chest pain and provides important information for the healthcare provider. Administering oxygen can help improve oxygenation and reduce the workload on the heart. Notifying the healthcare provider ensures that appropriate interventions are initiated promptly.
2. Question: What is the appropriate nursing action when a client develops an allergic reaction to a medication?
Answer: The appropriate nursing action when a client develops an allergic reaction to a medication is to stop the administration of the medication immediately, assess the client's condition, and notify the healthcare provider. Additionally, the nurse should document the reaction and any interventions taken.
Rationale: Stopping the medication administration helps prevent further allergic reactions. Assessing the client's condition is crucial to determine the severity of the reaction and provide appropriate interventions. Notifying the healthcare provider ensures that further treatment options are considered.
3. Question: How should the nurse position a client after a lumbar puncture?
Answer: After a lumbar puncture, the nurse should position the client flat in a supine position for several hours to prevent cerebrospinal fluid leakage and minimize the risk of complications. The nurse should also monitor the client for any signs of complications, such as headache or infection.
Rationale: Keeping the client in a supine position helps maintain pressure on the puncture site, reducing the risk of cerebrospinal fluid leakage. Monitoring for complications is essential to ensure early detection and intervention.
4. Question: What is the priority nursing intervention for a client experiencing a hypertensive crisis?
Answer: The priority nursing intervention for a client experiencing a hypertensive crisis is to administer antihypertensive medications as ordered by the healthcare provider and closely monitor the client's blood pressure. Additionally, the nurse should assess the client for signs of target organ damage and provide appropriate interventions.
Rationale: Administering antihypertensive medications helps lower the client's blood pressure and prevent further complications. Monitoring blood pressure allows for timely adjustments in medication dosages. Assessing for signs of target organ damage, such as chest pain or neurological deficits, helps identify complications that require immediate intervention.
5. Question: How should the nurse position a client with a suspected spinal cord injury?
Answer: When a client has a suspected spinal cord injury, the nurse should maintain the client in a neutral, midline alignment and immobilize the client's head and neck using a cervical collar or manual stabilization. The nurse should also avoid any movements that could potentially worsen the injury.
Rationale: Maintaining a neutral, midline alignment helps prevent further damage to the spinal cord. Immobilizing the head and neck reduces the risk of additional injury. Avoiding movements that could worsen the injury is crucial to prevent further neurological deficits.
6. Question: What is the priority nursing intervention for a client experiencing a seizure?
Answer: The priority nursing intervention for a client experiencing a seizure is to ensure the client's safety by protecting the client from injury. This can be done by removing any nearby objects that may cause harm and gently guiding the client to the floor if necessary. The nurse should also stay with the client, monitor the duration of the seizure, and provide emotional support afterward.
Rationale: Ensuring the client's safety is the top priority during a seizure. Removing objects that may cause harm reduces the risk of injury. Staying with the client and providing emotional support helps alleviate anxiety and promote a sense of security.
7. Question: What is the appropriate nursing action when a client develops a fever?
Answer: The appropriate nursing action when a client develops a fever is to assess the client's vital signs, monitor the temperature regularly, and administer antipyretic medications as ordered by the healthcare provider. Additionally, the nurse should encourage fluid intake and provide comfort measures, such as applying cool compresses or providing a fan.
Rationale: Assessing vital signs helps determine the severity of the fever and provides important information for the healthcare provider. Monitoring the temperature regularly helps evaluate the effectiveness of interventions. Administering antipyretic medications helps reduce the client's temperature. Encouraging fluid intake prevents dehydration, and comfort measures provide relief.
8. Question: What is the priority nursing intervention for a client experiencing respiratory distress?
Answer: The priority nursing intervention for a client experiencing respiratory distress is to provide oxygen therapy as ordered by the healthcare provider and monitor the client's respiratory status closely. The nurse should also assess the client's oxygen saturation levels and administer bronchodilators or other respiratory medications as necessary.
Rationale: Providing oxygen therapy helps improve oxygenation and alleviate respiratory distress. Monitoring the client's respiratory status allows for early detection of changes and prompt intervention. Assessing oxygen saturation levels helps evaluate the effectiveness of oxygen therapy. Administering respiratory medications helps relieve bronchospasm and improve breathing.
9. Question: What is the appropriate nursing action when a client develops a wound infection?
Answer: The appropriate nursing action when a client develops a wound infection is to assess the wound for signs of infection, such as redness, swelling, or purulent drainage. The nurse should notify the healthcare provider and obtain a wound culture if indicated. Additionally, the nurse should provide wound care, administer antibiotics as ordered, and educate the client on proper wound care techniques.
Rationale: Assessing the wound for signs of infection helps identify the presence of an infection and guide appropriate interventions. Notifying the healthcare provider and obtaining a wound culture help determine the appropriate antibiotic treatment. Providing wound care helps promote healing and prevent further complications. Educating the client on proper wound care techniques ensures their participation in the healing process.
10. Question: What is the priority nursing intervention for a client experiencing a severe allergic reaction (anaphylaxis)?
Answer: The priority nursing intervention for a client experiencing a severe allergic reaction (anaphylaxis) is to administer epinephrine immediately, as ordered by the healthcare provider, and initiate emergency protocols. The nurse should also assess the client's airway, breathing, and circulation, and provide additional interventions, such as administering antihistamines or corticosteroids.
Rationale: Administering epinephrine helps reverse the severe allergic reaction and prevent further complications. Initiating emergency protocols ensures a coordinated response to the client's condition. Assessing the client's airway, breathing, and circulation helps identify any life-threatening changes. Providing additional interventions, such as antihistamines or corticosteroids, helps manage the allergic reaction effectively.
In conclusion, understanding common NCLEX questions and their corresponding answers is crucial for success on the exam. By reviewing these questions and their rationales, students can enhance their critical thinking skills and improve their ability to make sound clinical judgments. Remember to always prioritize safety, assess the client's condition, and provide appropriate interventions. Good luck with your NCLEX preparation!