Questions 150

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Practice Questions with Answers Questions

Extract:


Question 1 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: Educating the client about the proper cane length (typically where the handle reaches the wrist when the arm is at the side) promotes safety and proper use without unnecessarily restricting mobility.

Question 2 of 5

During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?

Correct Answer: A

Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.

Question 3 of 5

A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.

Correct Answer: A,C,D

Rationale: Because the nurse is asking the woman, she would expect presumptive signs of pregnancy to be vocalized. Specifically the presumptive signs of pregnancy are nausea, vomiting, breast changes, amenorrhea, urinary frequency, fatigue, and quickening. Diarrhea is not a typical sign of early pregnancy, and increased energy is less common as fatigue is more typical.

Question 4 of 5

The nurse is caring for a client with a nasogastric tube. Which action confirms correct placement?

Correct Answer: A

Rationale: Checking the pH of aspirate (pH ‰¤ 5.5) confirms the tube is in the stomach, ensuring safe placement.

Question 5 of 5

The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?

Correct Answer: B

Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.

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