NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Assessment of the client with pericarditis may reveal which of the following?
Correct Answer: C
Rationale: No S3 or S4 are noted with pericarditis. No change in pulse pressure occurs. The symptoms of pericarditis vary with the cause, but they usually include chest pain, dyspnea, tachycardia, rise in temperature, and friction rub caused by fibrin or other deposits. The pain seen with pericarditis typically worsens with deep inspiration. Tamponade is not typically seen early on, and no change in pulse pressure occurs.
Question 2 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 3 of 5
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, 'It's not so easy for me to just go right to the hospital like that.' After acknowledging her feelings, which of these approaches by the nurse would probably be best?
Correct Answer: B
Rationale: This answer does not hold the client accountable for her own health. The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?
Question 4 of 5
A five-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
Correct Answer: A
Rationale: Atopic dermatitis involves itchy, broken skin prone to infection. Preventing infection through skin care and hygiene is critical. Antipyretics, dry skin, or fluid limits are not primary concerns.
Question 5 of 5
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute suggests magnesium toxicity as magnesium sulfate depresses the central nervous system including respiratory drive. Normal reflexes adequate urine output and BP of 140/90 do not indicate toxicity.