NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
Question 2 of 5
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TC
A). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.
Question 3 of 5
The nurse is caring for a client with a nasogastric tube in place for decompression. Which of the following actions is most appropriate to ensure proper functioning of the tube?
Correct Answer: C
Rationale: Checking tube placement every shift ensures the nasogastric tube remains in the stomach, preventing complications like aspiration.
Question 4 of 5
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
Correct Answer: D
Rationale: Safety during defibrillation is essential for preventing injury to the client and the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of 'all clear.' For the shock to be effective, some type of conductive medium (e.g., lubricant, gel) must be placed between the paddles and the skin. Both paddles are placed on the client's chest.
Question 5 of 5
Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
Correct Answer: A
Rationale: Drugs in FDA pregnancy categories C, D, and X carry risks (potential harm, known harm, or absolute contraindication, respectively) and are generally contraindicated in pregnancy unless benefits outweigh risks.