NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
Correct Answer: A
Rationale: This answer is correct. If the cause is removed, the delirious client will recover completely. This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.
Question 2 of 5
The nurse is teaching a client with a history of eczema about skin care. The nurse should tell the client to:
Correct Answer: A
Rationale: Avoiding harsh soaps prevents skin irritation and dryness in eczema, maintaining the skin barrier.
Question 3 of 5
The nurse is preparing to administer both regular and NPH insulin to a client with diabetes. Place in sequence the correct method for completing this task.
Correct Answer: C, D, B, A
Rationale:
To prevent contamination: Inject air into regular insulin vial (
C), then NPH vial (
D). Withdraw regular insulin (
B), then NPH insulin (
A). Regular insulin is clear, drawn first to avoid clouding with NPH.
Question 4 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.
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.