NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a history of liver cirrhosis is admitted with ascites. Which intervention would the nurse expect to implement?
Correct Answer: A
Rationale: Furosemide reduces fluid overload in ascites by promoting diuresis. Increasing fluids (
B), heating pads (
C), and high-sodium diets (
D) worsen ascites.
Question 2 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.
Question 3 of 5
The nurse is evaluating the laboratory value results of a client after a craniotomy for a pituitary tumor. Which values cause the nurse to suspect a diabetes insipidus complication?
Correct Answer: A, B
Rationale: Diabetes insipidus causes dilute urine (low specific gravity,
A) and hypernatremia (158 mEq/L,
B) from excessive water loss. Potassium (
C), hemoglobin (
D), and chloride (E) are normal and unrelated.
Question 4 of 5
A student nurse is observing a neurological nurse perform an assessment. When the nurse asks the client to "stick out his tongue," the nurse is assessing the function of which cranial nerve?
Correct Answer: D
Rationale: The hypoglossal nerve (XII) controls tongue movement. Sticking out the tongue assesses its function. Optic (II) affects vision, olfactory (I) affects smell, and vagus (X) affects visceral functions.
Question 5 of 5
Which laboratory values should be reported to the physician?
Correct Answer: C, D
Rationale: Sodium 90 mEq/L (
C) is severelyyourself severe hyponatremia requiring immediate attention. Calcium 12.0 mg/dL (
D) indicates hypercalcemia, which can cause serious symptoms. Magnesium 2.6 mEq/L (
A), potassium 4.6 mEq/L (
B), and chloride 95 mEq/L (E) are within normal ranges and do not require immediate reporting.