NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 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 2 of 5
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
Correct Answer: C
Rationale: Headaches may occur after taking nitroglycerin because of vasodilation. The tablets do not need to be refrigerated. The client should carry them with her. The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
Question 3 of 5
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
Correct Answer: C
Rationale: Blood pressure can remain normotensive even in a state of hypovolemia. Serum potassium is not reliable for determining adequacy of fluid resuscitation. Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
Question 4 of 5
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
Correct Answer: C
Rationale: G=3 (current pregnancy), T=1 (term birth), P=1 (preterm birth), A=0 (no abortions), L=2 (living children).
Question 5 of 5
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
Correct Answer: C
Rationale: Nudity is not a trigger for reminding males to perform TSE. Testicles become more firm when exposed to cool temperatures, but not large and bulky. The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. The examination should not be painful.