NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 2 of 5
A client being treated with sodium warfarin (Coumadin) has a prothrombin time of 120 seconds. The nurse recognizes that:
Correct Answer: A
Rationale: A prothrombin time of 120 seconds is excessively prolonged indicating a high bleeding risk. Close monitoring for bleeding (e.g. bruising hematuria) is critical. The dosage is not inadequate vitamin K restriction is routine and doubling doses is dangerous.
Question 3 of 5
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, 'My life is so bad no one can do anything to help me.' The most helpful initial response by the nurse would be:
Correct Answer: C
Rationale: This response does not acknowledge the client's feelings and may increase his feelings of guilt. This response denotes false reassurance. This response acknowledges the client's feelings and invites a response. This response changes the subject and does not allow the client to talk about his feelings.
Question 4 of 5
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
Correct Answer: A
Rationale: Dried beans are high in purines, which can exacerbate gout by increasing uric acid levels, so they should be avoided on a low-purine diet.
Question 5 of 5
Which of the following factors affects the accuracy of pulse oximetry readings?
Correct Answer: A, B, C
Rationale: Pulse oximetry accuracy is reduced by poor circulation (
A), improper probe placement (
B), and bright lighting (
C). Dark skin (
D) has minimal impact with modern sensors.