NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis.
Correct Answer: A
Rationale: Fluid volume deficit is the major problem. Symptoms of dehydration are evident, and rehydration is critical to prevent life-threatening complications.
Question 2 of 5
A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of:
Correct Answer: B
Rationale: Canned and frozen foods have a high sodium content. Labels of all canned foods should be read to determine if sodium is used in any form.
Question 3 of 5
The nurse is teaching a client with type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?
Correct Answer: D
Rationale: In type 1 diabetes, insulin requirements may change during illness, and skipping doses without medical guidance can lead to ketoacidosis. The other statements are correct: rotating sites prevents lipodystrophy, checking blood sugar guides dosing, and mixing insulins is allowed.
Question 4 of 5
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
Correct Answer: A
Rationale: Diminished femoral pulses in a newborn suggest coarctation of the aorta, a cardiac anomaly, due to reduced blood flow to the lower extremities. The other findings are normal or nonspecific.
Question 5 of 5
An 82-year-old former restaurant owner walks to the nursing station and states, 'I have to go. The restaurant opens at 11 am.' Which response by the nurse is the most appropriate?
Correct Answer: C
Rationale: This response cuts off communication with the client. It does not address her feelings. Reality orientation frequently does not work alone. Feelings must be addressed. Telling a client to calm down is frequently ineffective. Reminiscence is used here to reorient and recall past pleasant events. Talking about the restaurant will allay anxiety. This response may confirm to the client that she indeed does still own a restaurant, buying into her confusion. Her feelings and anxiety require nursing intervention.