NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A male client has heart failure. He has been instructed to gradually increase his activities. Which signs and symptoms of worsening heart failure should the nurse tell him to watch for that would indicate a need for him to lower his activity level?
Correct Answer: D
Rationale: Pain in the legs could be indicative of doing too much too quickly, but not of worsening heart failure. The client should be cautioned to increase his activities slowly. Thirst, weight loss, and frequent urination are not indicative of heart failure. The client should report these symptoms to his physician. Drowsiness and lethargy are not indicative of worsening heart failure. The client should report these symptoms to his physician. All of these symptoms indicate a worsening cardiac condition possibly associated with too much activity. The client's activity level should be evaluated.
Question 2 of 5
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
Correct Answer: A
Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
Question 3 of 5
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
Correct Answer: A
Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.
Question 4 of 5
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
Question 5 of 5
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The nurse should:
Correct Answer: A
Rationale: Ice reduces swelling and pain at the fracture site. Active motion is limited, dependent positioning increases swelling, and massage is not recommended.