NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
After instructing a primiparous client who is breast-feeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she states which of the following?
Correct Answer: A
Rationale: Varying the baby's position during feeding prevents nipple soreness, so using the same position indicates a need for further instruction.
Question 2 of 5
A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
Question 3 of 5
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
Correct Answer: D
Rationale: The client with myasthenia gravis has weakness after periods of exertion and near the end of the day. Medication therapy should assist in alleviating the weakness. The medication regimen may not be optimal if the client continues to experience fatigue. The nurse also works with the client to space out activities to conserve energy and regain muscle strength by resting between activities. The client is also instructed to take medication as prescribed.
Question 4 of 5
As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do?
Correct Answer: C
Rationale: Teaching the client about proper cane length (handle at wrist level when arm is relaxed) promotes safe and effective mobility.
Question 5 of 5
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.