NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:
Correct Answer: A
Rationale: Warm, moist heat will promote circulation and provide comfort. A sitz bath should be tried before medication is given. Pain medication can be given when other comfort measures such as a sitz bath and topical applications are ineffective. Kegel exercises facilitate sitting by decreasing tension on the episiotomy. They will not be effective for pain control or sustained comfort level. Ice packs are appropriate to apply in the first 12 hours post-delivery to produce vasoconstriction and to reduce edema to the area.
Question 2 of 5
On admission to the inpatient unit, a 34-year-old client is able to follow simple directions, but with great difficulty. He is worried about how he can keep clean in such a public place and repeatedly dusts his bureau, straightens his bed, and adjusts the clothes in his closet. The client is experiencing a severe level of anxiety. Which response by the nurse would be most therapeutic in initially attempting to reduce his anxiety?
Correct Answer: B
Rationale: Acknowledging the anxiety and channeling it into some positive activity, such as a unit tour, is therapeutic and helps reduce anxiety by providing distraction and orientation.
Question 3 of 5
A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory value indicates the medication is effective?
Correct Answer: A
Rationale: Epoetin alfa stimulates red blood cell production. A hemoglobin of 12 g/dL (
A) indicates effectiveness. Creatinine (
B), potassium (
C), and WBC (
D) are not directly affected.
Question 4 of 5
A 27-year-old male client is admitted to the acute care mental health unit for observation. He has recently lost his job, and his wife told him yesterday that she wants a divorce. The client is placed on suicide precautions. In assessing suicide potential, the nurse should pay close attention to the client's:
Correct Answer: C
Rationale: Assessing the client's level of insight is an important part of the mental status exam (MSE), but it does not reflect suicide potential. Assessing the client's thought processes is an important part of the MSE, but it does not reflect suicide potential. Assessing the client's mood and affect is an important part of the MSE, and it can be a very valuable indicator of suicide potential. Frequently a client who has decided to proceed with suicide plans will exhibit a suddenly improved mood and affect. Assessing a client's abstracting abilities is an important part of the MSE, but it does not reflect suicide potential.
Question 5 of 5
A client with a history of asthma is admitted with an acute exacerbation. The nurse should give priority to:
Correct Answer: A
Rationale: Bronchodilators are the first-line treatment for an acute asthma exacerbation to relieve bronchospasm and improve airflow.