NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A male client is undergoing cardiac tests. He has been instructed to wear a Holter monitor. The nurse knows she has included the appropriate information in her teaching when the client tells her:
Correct Answer: C
Rationale: The client should leave the electrodes in place during the entire time the test is ordered. He should not even remove the electrodes for bathing. The Holter monitor will record cardiac electrical activity but will not record damage to his myocardium. The client should keep a record of all of his activities so the physician can correlate the ECG findings with his activities. The client should continue doing his regular activities. The purpose of the Holter monitor is to record heart activity during routine activities.
Question 2 of 5
The nurse has just received a report from the previous shift.
Correct Answer: B
Rationale: Shortness of breath post-MVA suggests potential trauma (e.g., pneumothorax), requiring immediate assessment. COPD with PCO2 50 (
A) is stable, pain (
C) is less urgent, and mild fever (
D) is expected post-op.
Question 3 of 5
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 4 of 5
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, 'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:
Correct Answer: C
Rationale: Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
Question 5 of 5
Which observation would the nurse expect to make after an amniotomy?
Correct Answer: C
Rationale: After an amniotomy the nurse expects clear amniotic fluid. Greenish fluid suggests meconium dark yellow may indicate infection and red fluid indicates bleeding all of which are abnormal.