NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
Correct Answer: D
Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.
Question 2 of 5
The nurse is caring for a client with a history of cirrhosis. Which dietary restriction is most important?
Correct Answer: C
Rationale: Low sodium is critical in cirrhosis to reduce fluid retention and ascites caused by portal hypertension and hypoalbuminemia. Protein is moderated but not severely restricted, and fat and carbohydrates are less critical.
Question 3 of 5
Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and encouraging gentle hand movement. The other activities do not specifically alleviate joint stiffness.
Question 4 of 5
A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Correct Answer: D
Rationale: Diversion may help the child to focus on a pleasant activity instead of on his headache.
Question 5 of 5
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.