NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?
Correct Answer: C, E, F
Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.
Question 2 of 5
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1-2 minutes; strong, large amount of 'bloody show.' The most appropriate nursing goal for this client would be:
Correct Answer: C
Rationale: In transition (9 cm dilation, frequent contractions), helping the client maintain control is critical due to intense contractions and emotional challenges.
Question 3 of 5
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Correct Answer: C
Rationale: This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. This answer is correct. Manipulative clients must abide by consistent rules. This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
Question 4 of 5
A client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
Correct Answer: C
Rationale: Stomahesive is a skin barrier used to protect peristomal skin from irritation due to ileostomy output. Karaya powder is less common, daily irrigation is not needed for ileostomies, and stool softeners are irrelevant as output is liquid.
Question 5 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.