NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
Question 2 of 5
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
Correct Answer: B
Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.
Question 3 of 5
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?
Correct Answer: C
Rationale: Oral iron supplements are contraindicated in thalassemia. Although heart failure may be an end result of this disease, this action is unnecessary. Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. Children should be encouraged to pursue activities related to their exercise tolerance.
Question 4 of 5
A client with preeclampsia is admitted with an order for magnesium sulfate. Which action by the nurse indicates an understanding of magnesium toxicity?
Correct Answer: B
Rationale: Magnesium sulfate toxicity can cause respiratory depression or arrest. Placing an airway at the bedside prepares for potential emergency intervention. The other actions are less specific to managing magnesium toxicity.
Question 5 of 5
When interviewing parents who are suspected of child abuse, the nurse would use which of the following interview techniques?
Correct Answer: A
Rationale: The nurse must be honest, direct, professional, and attentive in her interview to gain the parent's trust. The nurse should approach the parents in private, away from the child. Asking them to relive and evaluate the situation may be looked at as placing blame on the parents for the child's 'accident.' At this point, the parents may get defensive and stop communicating. Although you may call child protective services, the nurse should inform the parents of their responsibility to do this and explain the process to them.