NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
Correct Answer: C
Rationale: Stomahesive is a skin barrier used to protect peristomal skin from irritation due to ileostomy output. Karaya powder is less common, daily irrigation is not needed for ileostomies, and stool softeners are irrelevant as output is liquid.
Question 2 of 5
Which of the following statements relevant to a suicidal client is correct?
Correct Answer: A
Rationale: This is a high-risk factor for potential suicide. A previous suicide attempt is a definite risk factor for subsequent attempts. Every threat of suicide should be taken seriously. The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.
Question 3 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 4 of 5
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.
Question 5 of 5
A client with a history of lymphoma is admitted with complaints of night sweats. The nurse should expect the client to have:
Correct Answer: A
Rationale: Night sweats are a B symptom of lymphoma, along with fever and weight loss, indicating systemic disease.