NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
Question 2 of 5
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
Question 3 of 5
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
Order the Items
Source Container
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.
Question 4 of 5
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
Question 5 of 5
The nurse is caring for a client with a history of myasthenia gravis. The nurse should assess the client for:
Correct Answer: A
Rationale: Myasthenia gravis causes autoimmune destruction of acetylcholine receptors, leading to muscle weakness, especially in the eyes, face, and limbs, a key assessment finding.