NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to:
Correct Answer: B
Rationale: Consistent limit setting will help the client to know what is acceptable behavior, addressing the disruptive actions effectively.
Question 2 of 5
A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states:
Correct Answer: C
Rationale: This is correct health teaching. Drinking 10-12 glasses of clear liquid will help increase urine volumes and prevent clot formation. This is correct health teaching. These types of exercises are prescribed by physicians to assist postprostatectomy clients to strengthen their perineal muscles. This action is not recommended post-TURP because of the close proximity of the prostate and rectum. This is correct healthcare teaching. The client should limit walking long distances, lifting heavy objects, or driving a car until these activities are cleared by the physician at the first office visit.
Question 3 of 5
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
Correct Answer: B
Rationale: Meperidine given close to delivery can cause neonatal respiratory depression due to its sedative effects crossing the placenta. The nurse should question the timing of the order.
Question 4 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 5 of 5
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
Correct Answer: D
Rationale: NG tube suction removes acids, leading to metabolic alkalosis, as indicated by the elevated pH (7.53).