NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A 24-year-old client presents to the emergency department protesting 'I am God.' The nurse identifies this as a:
Correct Answer: A
Rationale: A delusion is a false belief, such as claiming to be God, common in psychotic disorders.
Question 2 of 5
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (
B), elevated WBC (
C), and fever (
D) suggest possible infection.
Question 3 of 5
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.
Question 4 of 5
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
Correct Answer: B
Rationale:
Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
Question 5 of 5
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
Correct Answer: B
Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.