NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.
Question 2 of 5
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
Question 3 of 5
The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:
Correct Answer: C
Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.
Question 4 of 5
A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:
Correct Answer: A
Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.
Question 5 of 5
A female client comes for her second prenatal visit. The nurse-midwife tells her, 'Your blood tests reveal that you do not show immunity to the German measles.' Which notation will the nurse include in her plan of care for the client? 'Will need . . .
Correct Answer: D
Rationale: Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. The rubella vaccine is not given during pregnancy because of its teratogenicity. Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.