NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
Question 2 of 5
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, a common complication, so monitoring for anemia is the priority.
Question 3 of 5
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb).
Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
Question 4 of 5
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
Question 5 of 5
To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:
Correct Answer: B
Rationale: It is sufficient to rinse the plastic holders with warm water at least once per day. It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. 'Neutralizing' the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.