NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
Correct Answer: C
Rationale: Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. Rice contains about 4 g of protein per 200 g. Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. Green beans only contain 2 g of protein per cup.
Question 2 of 5
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 3 of 5
A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:
Correct Answer: B
Rationale: Canned and frozen foods have a high sodium content. Labels of all canned foods should be read to determine if sodium is used in any form.
Question 4 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 5 of 5
The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?
Correct Answer: A
Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.