NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
Correct Answer: A
Rationale: A supportive environment fosters trust and safety in PTSD, aiding recovery. Discussing the attack or controlling emotions may retraumatize, and hypnotics are secondary.
Question 2 of 5
A pregnant client complains of varicosities in the third trimester. Which of the following activities should she be advised to avoid?
Correct Answer: D
Rationale: Sitting with the legs crossed at the ankles does not interfere with circulation or create pressure points. TED stockings will help to reduce the varicosity by supporting the vein. Stockings must be applied with legs elevated. Support pantyhose help to reduce the varicosity by supporting the vein. They also provide support to the uterus and allow for better return circulation. Hose must be applied like TED stockings. Knee-high stockings create constriction and pressure points that interfere with circulation in the lower extremities.
Question 3 of 5
Which of the following is the best indicator of the diagnosis of HIV?
Correct Answer: C
Rationale: The Western blot is the confirmatory test for HIV diagnosis, detecting specific antibodies with high specificity. ELISA is a screening test, while WBC and CBC are non-specific and not diagnostic for HIV.
Question 4 of 5
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
Correct Answer: B
Rationale: This problem is usually temporary, but it may take some time to resolve.
Question 5 of 5
A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel decompression. When preparing to insert a NG tube, the nurse measures from the:
Correct Answer: D
Rationale: This measurement is ~50 cm (48-49 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement is ~50 cm (47-48 cm). Fifty centimeters is considered the length necessary for the distal end of the tube to be in place in the stomach. This measurement is too short. This measurement gives an approximate indication of the length necessary for the distal end of the tube to be in place in the stomach, but it is not as accurate as actually measuring the client (nose-ear-xiphoid). This is the correct measurement of 50 cm from the tip of the client's nose to the tip of the earlobe to the xiphoid process (called the NEX [nose-ear-xiphoid] measurement). It is approximately equal to the distance necessary for the distal end of the tube to be located in the correct position in the stomach.