NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a history of pneumonia is admitted with complaints of dyspnea. The nurse should give priority to:
Correct Answer: A
Rationale: Dyspnea in pneumonia indicates impaired gas exchange, so administering oxygen is the priority to improve oxygenation.
Question 2 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 3 of 5
A client with polycythemia vera is admitted with complaints of difficulty breathing and pleuritic pain. Which lab finding is expected in the client with polycythemia vera?
Correct Answer: A
Rationale: Polycythemia vera is characterized by excessive red blood cell production, leading to an increased red blood cell count, which can cause hyperviscosity and symptoms like dyspnea.
Question 4 of 5
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute suggests magnesium toxicity as magnesium sulfate depresses the central nervous system including respiratory drive. Normal reflexes adequate urine output and BP of 140/90 do not indicate toxicity.
Question 5 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.