NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence. The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information:
Correct Answer: A
Rationale: The client has insight into the severity of his alcohol addiction and has chosen one of the most effective treatment strategies to support him--Alcoholics Anonymous.
Question 2 of 5
A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must:
Correct Answer: B
Rationale: Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
Question 3 of 5
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
Correct Answer: D
Rationale: Weight should be obtained daily. Fluid is not restricted but is given according to urine output. The medication does not have to be stored in a refrigerator. Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
Question 4 of 5
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
Correct Answer: A
Rationale: Diminished femoral pulses in a newborn suggest coarctation of the aorta, a cardiac anomaly, due to reduced blood flow to the lower extremities. The other findings are normal or nonspecific.
Question 5 of 5
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to:
Correct Answer: C
Rationale: This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. Sacral pressure will counteract the pressure created by the position of the fetal head. The client is not completely dilated. Pushing is contraindicated until the second stage of labor.