NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.
Question 2 of 5
A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:
Correct Answer: A
Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.
Question 3 of 5
A client has been in labor for 10 hours. Her contractions have become hypoactive and slowed in duration. The fetus is at 0 station, cervix is dilated 8 cm and effaced 90%. The physician orders an oxytocin (Pitocin) infusion to be started at once. The RN begins the oxytocin infusion. It is important that the RN discontinue the infusion if which one of the following occur?
Correct Answer: A
Rationale: Contractions less than 2 minutes apart indicate hyperstimulation, which can reduce uterine blood flow, leading to fetal hypoxia. The infusion should be discontinued to prevent complications.
Question 4 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 5 of 5
The nurse is caring for a client post-appendectomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: A temperature of 101.5°F post-appendectomy suggests infection (e.g., abscess), requiring immediate intervention. Pain (
A), serous drainage (
C), and absent bowel sounds (
D) are expected initially.