NCLEX-RN
Free NCLEX RN Exam Questions
Extract:
Question 1 of 5
A client with a history of chronic migraines is admitted with complaints of photophobia. The nurse should give priority to:
Correct Answer: A
Rationale: A dark environment reduces photophobia in migraines, improving comfort and reducing symptom severity.
Question 2 of 5
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
Correct Answer: B
Rationale: Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk.
Question 3 of 5
A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
Correct Answer: B
Rationale: A 2-lb weight gain in 24 hours suggests fluid retention due to decreasing cardiac output, activating the renin-angiotensin-aldosterone system.
Question 4 of 5
The client is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should prepare to administer which medication?
Correct Answer: C
Rationale: Betamethasone is administered in PPROM (24-34 weeks) to enhance fetal lung maturity in anticipation of preterm delivery. Magnesium sulfate may be used for neuroprotection or preeclampsia and terbutaline is a tocolytic but betamethasone is the priority.
Question 5 of 5
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.