NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.
Question 2 of 5
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
Question 3 of 5
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
Question 4 of 5
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
Question 5 of 5
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.