NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
Question 2 of 5
A client is 6 weeks pregnant. During her first prenatal visit, she asks, 'How much alcohol is safe to drink during pregnancy?' The nurse's response is:
Correct Answer: D
Rationale: No amount of alcohol has been determined safe for pregnant women. Alcohol should be avoided owing to the risk of fetal alcohol syndrome. The recommended safe dosage of alcohol consumption during pregnancy is none.
Question 3 of 5
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.
Question 4 of 5
A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
Correct Answer: C
Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
Question 5 of 5
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
Correct Answer: D
Rationale: Full-thickness circumferential burns are nonelastic and create an internal tourniquet effect, compromising distal blood flow in extremities or respiratory motion in the torso, leading to loss of peripheral pulses.