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
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 3 of 5
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
Correct Answer: D
Rationale: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 4 of 5
Which of the following interventions will be useful for the patient with Alzheimer's dementia who exhibits prosopagnosia?
Correct Answer: B
Rationale: Prosopagnosia is the inability to recognize faces. Labeled pictures of family and friends can help the patient identify familiar people improving social interaction and reducing confusion. The other options do not directly address face recognition.
Question 5 of 5
The nurse is caring for a client with a history of a fractured ankle who is in a cast. The client complains of numbness and tingling. The nurse should:
Correct Answer: C
Rationale: Numbness and tingling suggest neurovascular compromise (e.g., compartment syndrome), requiring immediate physician notification. Ice, elevation, and massage are insufficient.