Nursing Process NCLEX Questions

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac

Correct Answer: D

Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank. Rationale: 1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction. 2. Infuse normal saline solution to maintain adequate hydration and support kidney function. 3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing. Summary of other choices: A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical. B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively. C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.

Correct Answer: C

Rationale: The correct answer is C. The nurse should respond by asking, �Do you take anything to help your constipation?� This response shows active listening and gathers more information about the woman�s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.

Correct Answer: A

Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.

Correct Answer: C

Rationale: The correct answer is C because jaundice is a common manifestation of sickle cell anemia due to the breakdown of red blood cells. The nurse should inspect the skin and sclera for the characteristic yellow discoloration indicating jaundice. This assessment is specific to identifying jaundice, which is directly related to the disease process. Choice A is incorrect as it relates to assessing neurological function, not jaundice. Choice B is incorrect as joint swelling is not a typical sign of jaundice in sickle cell anemia. Choice D is incorrect as a urine specimen is not used to assess jaundice; skin and sclera inspection are more appropriate.