NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client with Addison's disease is receiving Solu-Medrol (methylprednisolone). Which of the following interventions would the nurse implement?
Correct Answer: C
Rationale: Addison’s disease involves adrenal insufficiency and methylprednisolone replaces deficient corticosteroids. Monitoring sodium and potassium levels is essential as Addison’s can cause hyperkalemia and hyponatremia which may be affected by steroid therapy.
Question 2 of 5
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to:
Correct Answer: D
Rationale: A full bladder is the most common cause of uterine displacement; having the client void addresses this before further interventions.
Question 3 of 5
The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
Correct Answer: C
Rationale: The most immediate action in cases of suspected fetal distress or hyperstimulation during labor induction with Pitocin is to stop the Pitocin infusion to reduce uterine stimulation and improve fetal oxygenation. Other actions like vaginal exams or pushing are inappropriate without further assessment, and positioning is secondary.
Question 4 of 5
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
Correct Answer: C
Rationale: Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room. The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
Question 5 of 5
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
Correct Answer: B
Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.