NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 2 of 5
The nurse is preparing to administer a dose of insulin lispro (Humalog). When is the onset of action for this medication?
Correct Answer: A
Rationale: Insulin lispro, a rapid-acting insulin, has an onset of 5–15 minutes, making it ideal for pre-meal administration. Other insulins have slower onsets.
Question 3 of 5
A male client is being treated in the burn unit for third-degree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
Correct Answer: C
Rationale: A weight gain of 10 lb represents a state of overhydration. He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.
Question 4 of 5
A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should advise him to:
Correct Answer: C
Rationale: Smoking on a full stomach minimizes nicotine's effect on gastric acid, reducing ulcer irritation. Other options still stimulate gastric acid secretion.
Question 5 of 5
The client at 28 weeks gestation is admitted with a diagnosis of preterm labor. The physician orders a non-stress test. The nurse should explain to the client that this test is used to:
Correct Answer: C
Rationale: A non-stress test (NST) evaluates fetal well-being by monitoring fetal heart rate accelerations in response to movement. It does not assess lung maturity contractions or maternal hypertension.