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
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
Correct Answer: C
Rationale: Increased PaCO2 is present in both acute and chronic respiratory acidosis due to hypoventilation. Decreased PaO2 may occur in respiratory acidosis but does not differentiate acute from chronic. Increased HCO3 indicates renal compensation, which occurs in chronic respiratory acidosis as the body attempts to buffer the excess CO2, but not in acute cases where compensation has not yet occurred. Decreased base excess is not specific to differentiating acute from chronic respiratory acidosis.
Question 3 of 5
The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:
Correct Answer: A
Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.
Question 4 of 5
The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?
Correct Answer: D
Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
Question 5 of 5
The client is admitted with a diagnosis of gastroenteritis. Which precaution should the nurse implement?
Correct Answer: B
Rationale: Gastroenteritis is often caused by pathogens like norovirus, requiring contact precautions to prevent fecal-oral transmission. Standard precautions are insufficient, and droplet or airborne are not indicated.