NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, 'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:
Correct Answer: C
Rationale: Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
Question 2 of 5
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
Correct Answer: B
Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.
Question 3 of 5
Which observation would the nurse expect to make after an amniotomy?
Correct Answer: C
Rationale: After an amniotomy the nurse expects clear amniotic fluid. Greenish fluid suggests meconium dark yellow may indicate infection and red fluid indicates bleeding all of which are abnormal.
Question 4 of 5
The nurse is caring for a client with a recent stroke. Which position is most appropriate for this client?
Correct Answer: C
Rationale: Side-lying with the head elevated 30 degrees reduces intracranial pressure and promotes venous drainage in stroke clients, minimizing complications like cerebral edema. Supine, prone, or sitting positions may increase pressure or risk aspiration.
Question 5 of 5
Which is true regarding the administration of antacids?
Correct Answer: C
Rationale: Antacids can bind to other medications, reducing their absorption, so they should be administered at least 1–2 hours apart from other drugs. Timing with meals depends on the condition, and they are not given with every meal/snack or to enhance other drug absorption.