NCLEX Questions, NCLEX-RN Exam Questions, NCLEX-RN Questions

Extract:

Question 1 of 5

A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that:

Correct Answer: D

Rationale: Keeping the leg straight for 8-12 hours minimizes bleeding risk at the arterial puncture site after coronary arteriography.

Question 2 of 5

The client is admitted with a diagnosis of molar pregnancy. Which diagnostic test is most appropriate?

A. Ultrasound B. Serum hCG levels C. Both A and B D. Neither A nor B

Correct Answer: C

Rationale: Ultrasound reveals the characteristic “snowstorm” pattern of molar pregnancy and elevated serum hCG levels confirm the diagnosis. Both tests are essential.

Question 3 of 5

A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?

A. Emphasize those aspects of the procedure that require cooperation. B. Tell the child not to cry or yell. C. Tell the child that he will get a 'stick' in his back. D. Use medical terminology when explaining the procedure to the client.

Correct Answer: A

Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.

Question 4 of 5

The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

A. Pulse rate of 50-70 bpm by her third postpartum day B. Diuresis by her second or third postpartum day C. Vaginal discharge or rubra, serosa, then rubra D. Diaphoresis by her third postpartum day

Correct Answer: C

Rationale: Bradycardia is an expected assessment during the postpartum period. Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. A return of rubra after the serosa period may indicate a postpartal complication. Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.

Question 5 of 5

A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:

A. Repression B. Regression C. Reaction formation D. Rationalization

Correct Answer: D

Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.