NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
A nurse has been working with a battered woman who is being discharged and returning home with her husband. The nurse says, 'All this work with her has been useless. She's just going back to him as usual.' Which of the following statements by a nursing colleague would be most helpful to this nurse?
Correct Answer: A
Rationale: The colleague needs to provide the nurse with information about spouse abuse. Giving information about reasons for staying is useful for decreasing the nurse's frustration. Although expressing empathy is appropriate, it does not help the nurse understand the client's needs and behaviors. Telling the nurse that there will be another chance is not helpful and fails to educate the other nurse about the dynamics of abuse. Although dependence is a problem, women who are abused can overcome this and leave if they have support, not criticism.
Question 2 of 5
A primiparous client at 38 weeks' gestation is admitted in early labor. The client's membranes rupture, and the nurse observes that the amniotic fluid is meconium-stained. The nurse should:
Correct Answer: A
Rationale: Meconium-stained amniotic fluid may indicate fetal distress, requiring immediate notification of the physician for further evaluation and management.
Question 3 of 5
Which action by the new nurse when initiating continuous electrocardiogram (ECG) monitoring on a client should indicate to the registered nurse the need for further teaching?
Correct Answer: D
Rationale: The skin is cleansed with soap and water (not povidone-iodine), denatured with alcohol, and allowed to air-dry before electrodes are applied. The other three options are correct measures.
Question 4 of 5
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.
Question 5 of 5
A mother who is Mexican brings her 2-month-old son to the emergency department with a high fever and possible sepsis. A lumbar puncture is ordered, but the mother will not sign the consent until the father arrives to give permission. The nurse should:
Correct Answer: C
Rationale: Respecting cultural norms, where the father may be the decision-maker, the nurse should wait for the father to arrive for consent, especially in a non-immediate life-threatening situation. Reporting to social services or claiming refusal is premature without further assessment.