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 is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
Correct Answer: C
Rationale: Paresthesia of hands and feet indicates B12 deficiency due to noncompliance with injections, as B12 is needed for nerve function. Hyperactivity (
A), weight gain (
B), and diarrhea (
D) are not specific to B12 deficiency.
Question 3 of 5
The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:
Correct Answer: B
Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.
Question 4 of 5
A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
Correct Answer: B
Rationale: Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
Question 5 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.