NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
Question 2 of 5
The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?
Correct Answer: A
Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a hematoma. Because the client received anesthesia, she would not feel pain or pressure.
Question 3 of 5
The nurse is caring for a client with a history of liver cirrhosis who is prescribed lactulose (Cephulac). The nurse should expect the client to experience which of the following effects?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels in cirrhosis by promoting its excretion, preventing hepatic encephalopathy.
Question 4 of 5
Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply.
Correct Answer: B,C
Rationale: Adequate protein supports liver repair, and small, frequent meals reduce metabolic stress in early cirrhosis. Alcohol should be avoided, and fluid restriction is not typically needed early on.
Question 5 of 5
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.