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 receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction.
Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
Question 3 of 5
A client with bipolar disorder is admitted during a depressive episode. Which intervention should the nurse prioritize?
Correct Answer: B
Rationale: During a depressive episode, monitoring for suicidal ideation is the priority to ensure client safety, given the high risk of suicide in bipolar depression.
Question 4 of 5
A client with a history of depression is prescribed mirtazapine (Remeron). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Mirtazapine commonly causes weight gain.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of celiac disease about dietary modifications. Which of the following foods should the client avoid?
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease to prevent intestinal damage.