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 with a history of polycystic kidney disease has an order for an indwelling catheter. The nurse should give priority to:
Correct Answer: A
Rationale: Sterile technique during catheter insertion is critical in polycystic kidney disease to prevent urinary tract infections, which can worsen renal function. Bag position and clamping are secondary.
Question 3 of 5
A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?
Correct Answer: A
Rationale: Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However, clients must consider the time that they spend traveling to the dialysis center and the disruption in their daily lives. Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and therefore takes longer than hemodialysis. Several serious complications of peritoneal dialysis include peritonitis, catheter displacement and/or plugging, or pain during dialysis. A client can be taught to self-administer peritoneal dialysis without the aid of a professional.
Question 4 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: A
Rationale: High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C,
D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
Question 5 of 5
A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:
Correct Answer: B
Rationale: Respiratory acidosis is determined by low pH and elevated PaCO2.