NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
Question 2 of 5
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, 'I just couldn't take it anymore.' The nurse's best response to this disclosure would be:
Correct Answer: B
Rationale: Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. Giving a broad opening gives the client encouragement to continue with verbalization. Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
Question 3 of 5
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
Correct Answer: A
Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.
Question 4 of 5
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
Question 5 of 5
A client with a history of heart failure is receiving Spironolactone (Aldactone). The nurse should teach the client to:
Correct Answer: A
Rationale: Spironolactone, a potassium-sparing diuretic, risks hyperkalemia, so potassium-rich foods should be avoided. Sodium restriction, daytime dosing, and fluid management are secondary.