NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?
Correct Answer: D
Rationale: This expected outcome is specific as related to attendance, but not specific as related to outcome criteria. Stating activities does not guarantee involvement. This goal may help the recovery process, but post counseling behavior is not addressed. This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.
Question 2 of 5
The nurse is in the hallway and one of the visitors faints. The nurse should:
Correct Answer: B
Rationale: Sitting the client up defeats the goal of re-establishing cerebral blood flow. Elevating the legs anatomically redirects blood flow to the cerebral area. This strategy is a nice general comfort measure after the victim has regained consciousness. This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
Question 3 of 5
The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of:
Correct Answer: C
Rationale: Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
Question 4 of 5
A client is scheduled for a biologic heart valve replacement. The nurse is aware that the client will require:
Correct Answer: C
Rationale: Biologic (tissue) heart valves are prone to bacterial endocarditis. Strict dental hygiene prevents infections that could seed the valve. Lifelong anticoagulation is typically for mechanical valves and the other options are not specific to biologic valves.
Question 5 of 5
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.