NCLEX Questions, NCLEX RN Exam Questions Questions, NCLEX-RN

Extract:

Question 1 of 5

A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:

Correct Answer: D

Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.

Question 2 of 5

Which instruction should be given to the client who has been prescribed a dry powder inhaler for treatment of COPD?

A. Remove the mouthpiece cap and shake before using. B. Rinse the inhaler mouthpiece and spacer after each use. C. Use a spacer or hold the canister two fingerbreadths away from the mouth. D. Place the mouthpiece directly in the mouth. E. Clean the mouthpiece weekly using a dry cloth.

Correct Answer: A, D, E

Rationale: Dry powder inhaler use involves removing the cap and shaking (
A), placing the mouthpiece in the mouth (
D), and weekly dry cleaning (E). Rinsing (
B) risks moisture damage, and spacers (
C) are typically for metered-dose inhalers.

Question 3 of 5

A client with SIADH is admitted with severe hyponatremia. Which type of intravenous solution would the nurse expect to be ordered?

A. Isotonic (0.9% normal saline) B. Hypertonic (3% sodium chloride) C. Colloid (Dextran) D. Hypotonic (5% dextrose in water)

Correct Answer: B

Rationale: SIADH causes water retention and severe hyponatremia. Hypertonic 3% sodium chloride is used to correct low sodium levels by drawing water out of cells. Isotonic or hypotonic fluids may worsen hyponatremia and colloids are not indicated.

Question 4 of 5

The nurse has just received a report from the previous shift.

A. A 50-year-old COPD client with a PCO2 of 50 B. A 24-year-old admitted after an MVA complaining of shortness of breath C. A client with cancer requesting pain medication D. A one-day post-operative cholecystectomy with a temperature of 100°F

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 5 of 5

The client's membranes rupture during labor. The fetal heart rate suddenly drops to 90 bpm. The nurse's first action should be to:

A. Increase the rate of the IV fluid B. Turn the client on her left side C. Notify the physician immediately D. Apply oxygen by mask at 8-10 liters

Correct Answer: B

Rationale: A sudden drop in fetal heart rate to 90 bpm after membrane rupture suggests possible umbilical cord prolapse or compression. Turning the client to her left side improves placental perfusion and may relieve cord compression. Oxygen and notifying the physician are secondary and increasing IV fluid is less urgent.