NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:
Correct Answer: A
Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.
Question 2 of 5
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.
Question 3 of 5
During burn therapy, morphine is primarily administered IV for pain management because this route:
Correct Answer: B
Rationale: IM injections are unreliable in burn patients due to fluid shifts into interstitial spaces, leading to poor absorption. IV administration ensures dependable absorption and effective pain relief.
Question 4 of 5
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
Question 5 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.