NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a history of epilepsy is admitted with complaints of aura. The nurse should give priority to:
Correct Answer: A
Rationale: An aura signals an impending seizure, so ensuring safety (e.g., padding, side-lying position) is the priority.
Question 2 of 5
A client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
Correct Answer: C
Rationale: Stomahesive is a skin barrier used to protect peristomal skin from irritation due to ileostomy output. Karaya powder is less common, daily irrigation is not needed for ileostomies, and stool softeners are irrelevant as output is liquid.
Question 3 of 5
The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:
Correct Answer: D
Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
Question 4 of 5
A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?
Correct Answer: B
Rationale: Pegfilgastrim stimulates neutrophil production, increasing white blood cell counts. A WBC of 6,000/mm (
B) indicates effectiveness. Hemoglobin (
A), platelets (
C), and hematocrit (
D) are not directly affected.
Question 5 of 5
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
Correct Answer: C
Rationale: Bradycardia is an expected assessment during the postpartum period. Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. A return of rubra after the serosa period may indicate a postpartal complication. Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.