NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: A
Rationale: High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C,
D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
Question 2 of 5
A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:
Correct Answer: D
Rationale: Sterile pin care prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.
Question 3 of 5
The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering. This statement is made by the nurse based on the knowledge that:
Correct Answer: C
Rationale: Nudity is not a trigger for reminding males to perform TSE. Testicles become more firm when exposed to cool temperatures, but not large and bulky. The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. The examination should not be painful.
Question 4 of 5
A client with a history of a burn injury is receiving Silvadene (silver sulfadiazine). The nurse should monitor the client for:
Correct Answer: A
Rationale: Silver sulfadiazine can cause neutropenia, requiring monitoring of white blood cell counts. Hyperkalemia, hypoglycemia, and hypertension are not typical side effects.
Question 5 of 5
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
Correct Answer: D
Rationale: Conversion disorder involves sensory or motor symptoms, like blindness, without an organic cause, often linked to psychological stress.