NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?
Correct Answer: B
Rationale: Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question 2 of 5
A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?
Correct Answer: B
Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.
Question 3 of 5
While caring for a client in the second stage of labor, the nurse notices a pattern of early decelerations. The nurse should:
Correct Answer: D
Rationale: Early decelerations are benign, caused by fetal head compression during labor, and require only documentation, as they do not indicate fetal distress.
Question 4 of 5
The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:
Correct Answer: B
Rationale: Asking 'why' questions may put the child on the defensive and may not elicit useful information, especially in a young child who may struggle to articulate reasons. This approach is open-ended and encourages the child to describe her experiences in a non-confrontational way, which may reveal underlying issues while building trust. This question is too specific and may feel confrontational, potentially causing the child to shut down. While encouraging expression of feelings is appropriate, it is less specific and may not help uncover the specific event or change that led to her refusal to attend.
Question 5 of 5
A common complaint of the client with an abdominal aortic aneurysm is:
Correct Answer: D
Rationale: A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.