NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
Correct Answer: D
Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
Question 2 of 5
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question 3 of 5
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.
Question 4 of 5
A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention?
Correct Answer: B
Rationale: The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
Question 5 of 5
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency. Replenishing every three months is not standard taking tablets every 15 minutes is incorrect (typically every 5 minutes up to 3 doses) and crushing is not appropriate.