NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
Correct Answer: D
Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.
Question 2 of 5
The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
Correct Answer: C
Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.
Question 3 of 5
An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent?
Correct Answer: 31.50%
Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of posterior torso equaling 9%. This totals 31.5%.
Question 4 of 5
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
Question 5 of 5
Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.