NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states:
Correct Answer: C
Rationale: The client will have minimal difficulty swallowing after a vertical partial laryngectomy, indicating effective preoperative teaching. Special swallowing training is typically required for supraglottic (horizontal partial) laryngectomy, not vertical. Voice quality will be altered, and radical neck dissection is associated with total laryngectomy.
Question 2 of 5
The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:
Correct Answer: C
Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.
Question 3 of 5
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
Correct Answer: B
Rationale: A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying.
Question 4 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 5 of 5
Following a bicycle accident, a 12-year-old client sustained a complete fracture of the left femur. He was placed in 90-90 skeletal traction with a pin in the distal end of the femur to achieve realignment and immobilization of the left femur. When providing nursing care, it is important for the nurse to remember that:
Correct Answer: B
Rationale: It is necessary to keep the pin site clean and free from infection, which is critical in skeletal traction care.