NCLEX-RN
Mock NCLEX RN Exam Questions
Extract:
Question 1 of 5
An elderly client refuses to take her daily medication for hypertension. Which action should the nurse take at this time?
Correct Answer: D
Rationale: Exploring the reason for the client’s refusal respects autonomy and may reveal misunderstandings, fears, or side effects that can be addressed. Administering by injection or with help violates autonomy, and skipping the dose delays treatment without addressing the issue.
Question 2 of 5
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.
Question 3 of 5
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
Question 4 of 5
The client at 30 weeks gestation is admitted with preterm labor. The physician orders indomethacin. The nurse should monitor for which side effect?
Correct Answer: C
Rationale: Indomethacin a tocolytic can reduce fetal urine output leading to oligohydramnios (low amniotic fluid). Maternal hypertension fetal bradycardia and hypoglycemia are not common side effects of indomethacin.
Question 5 of 5
The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:
Correct Answer: B
Rationale: A fetal heart rate of 80-90 during contractions indicates bradycardia possibly from cord compression or uteroplacental insufficiency. Turning the client to her left side improves placental perfusion and is the first action.