LATEST NCLEX RN COMPREHENSIVE EXAM 120 STUDY QUESTIONS AND ANSWERS WITH RATIONALES GUARANTEED PASS | RATED A+

LATEST NCLEX RN COMPREHENSIVE EXAM 120 STUDY QUESTIONS AND ANSWERS WITH RATIONALES GUARANTEED PASS | RATED A+
1. When prioritizing care, which of the following clients should the nurse Olivia assess first?
ï‚· A. A 17-year-old client 24-hours post appendectomy.
ï‚· B. A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome.
ï‚· C. A 50-year-old client 3 days post myocardial infarction.
ï‚· D. A 50-year-old client with diverticulitis.
Correct Answer: B. A 33-year-old client with a recent diagnosis of Guillain-Barre
syndrome
Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure.
The order of client assessment should follow client priorities, with disorder of airways,
breathing, and then circulation.
ï‚· Option A: The client who is post appendectomy has no signs of hemorrhage or
unstable vital signs. Possible complications of appendectomy are bleeding, wound
infection, peritonitis, blocked bowels, and injury to nearby organs.
ï‚· Option C: There’s no information to suggest the postmyocardial infarction client
has an arrhythmia or other complication. About 90% of patients who have an
acute MI develop some form of cardiac arrhythmia during or immediately after
the event.
ï‚· Option D: There’s no evidence to suggest perforation for the client with
diverticulitis as a priority of care. Diverticula are small, bulging pouches that can
form in the lining of the digestive system.when one or more of the pouches
become inflamed, and in some cases infected, that condition is known as
diverticulitis.
2. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment
of gout. Which of the following actions of colchicines explains why it’s effective for gout?
ï‚· A. Replaces estrogen.
ï‚· B. Decreases infection.
ï‚· C. Decreases inflammation.
ï‚· D. Decreases bone demineralization.
Correct Answer: C. Decreases inflammation.
The action of colchicines is to decrease inflammation by reducing the migration of leukocytes to
synovial fluid.
ï‚· Option A: Colchicine does not replace estrogen. Colchicine works by reducing
the inflammation caused by crystals of uric acid in the joints.
ï‚· Option B: Decreasing infection is not a mechanism of action of colchicine. The
primary mechanism of action of colchicine is tubulin disruption. This leads to
subsequent downregulation of multiple inflammatory pathways and modulation of
innate immunity.
ï‚· Option D: Colchicine doesn’t decrease bone demineralization. The toxic effects
of colchicine are related to this anti-mitotic activity within proliferating tissue
such as skin, hair, and bone marrow.
3. A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe
anemia. Which of the following is the most accurate statement?
ï‚· A. Transfusion reaction is most likely immediately after the infusion is
completed.
ï‚· B. PRBCs are best infused slowly through a 20g. IV catheter.
ï‚· C. PRBCs should be flushed with a 5% dextrose solution.
ï‚· D. A nurse should remain in the room during the first 15 minutes of
infusion.
Correct Answer: D. A nurse should remain in the room during the first 15 minutes of
infusion.
Transfusion reaction is most likely during the first 15 minutes of infusion, and a nurse should be
present during this period.
ï‚· Option A: Transfusion reaction most likely occurs during the first 15 minutes,
not after the infusion has been completed.
ï‚· Option B: PRBCs should be infused through a 19g or larger IV catheter to avoid
slow flow, which can cause clotting.
ï‚· Option C: PRBCs must be flushed with 0.45% normal saline solution. Other
intravenous solutions will hemolyze the cells.
4. A nurse on the surgical floor is prioritizing care for clients after receiving the report from the
previous shift. Which of the following patients should the nurse assess first?
ï‚· A. A 35-year-old patient admitted three hours ago for a gunshot wound, with
a 1.5 cm area of dark drainage noted on the dressing.
ï‚· B. A 43-year-old patient who underwent a mastectomy two days ago, with 23
ml of serosanguinous fluid in the Jackson-Pratt drain.
ï‚· C. A 59-year-old patient with a history of a collapsed lung from an
accident, with no drainage noted in the chest tube in the past eight hours.
ï‚· E. A 54-year-old patient with a total knee replacement two days ago, with
moderate swelling at the surgical site.
ï‚· E. A 47-year-old patient who had a laparoscopic cholecystectomy yesterday,
complaining of mild pain at the incision site.
ï‚· F. A 62-year-old patient who had an abdominal-perineal resection three
days ago, now reporting chills.
Correct Answer: F. A 62-year-old patient who had an abdominal-perineal resection three
days ago, now reporting chills.
The client is at risk for peritonitis; should be assessed for further symptoms and infection.

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