NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
Correct Answer: C
Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
Question 2 of 5
The physician has ordered a 24-hour urine collection for a client. Which instruction should the nurse provide?
Correct Answer: A
Rationale: For a 24-hour urine collection, the first void is discarded, and all subsequent urine is collected for exactly 24 hours to ensure accurate measurement of analytes. A single container is used, refrigeration is advised, but separate voids are not needed.
Question 3 of 5
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?
Correct Answer: A
Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.
Question 4 of 5
Which information should be given to the client using a TENS unit?
Correct Answer: B
Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.
Question 5 of 5
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
Correct Answer: C
Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.