NCLEX-RN
NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:
Correct Answer: B
Rationale: The mother's statement suggests caregiver role strain due to the ongoing stress of managing the client's schizophrenia symptoms.
Question 2 of 5
The nurse is caring for a group of clients who are experiencing pain. Which client is the priority for the nurse to see first?
Correct Answer: C
Rationale: Severe chest pain from an acute MI is life-threatening, making this client the priority for immediate assessment and intervention.
Question 3 of 5
A client with schizophrenia has been taking Thorazine (chlorpromazine) 200 mg four times a day. Which finding should be reported to the doctor immediately?
Correct Answer: C
Rationale: A sore throat may indicate agranulocytosis, a serious side effect of chlorpromazine, requiring immediate reporting.
Question 4 of 5
The nurse is assessing a client who had a colon resection 2 days ago. The client states, 'I feel like my stitches have burst loose.' Upon further assessment, dehiscence of the wound is noted. The nurse should:
Correct Answer: B
Rationale: Dehiscence requires covering the wound with a sterile, saline-moistened dressing to prevent infection and protect exposed tissues. The other actions are inappropriate or harmful.
Question 5 of 5
The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA?
Correct Answer: A
Rationale: Leaving the stethoscope in the room prevents MRSA transmission, as it avoids contaminating other areas or clients.