NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, 'Forget all those rules. I always get along well with the nurses.' Which nursing response to him would be most effective?
Correct Answer: B
Rationale: This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. This answer is incorrect. It appears to have a negative connotation. There was no limit setting. This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.
Question 2 of 5
The nurse is caring for a client with a spinal cord injury at C5. Which complication is the client at greatest risk for?
Correct Answer: A
Rationale: A C5 spinal cord injury impairs diaphragm function (innervated by C3–C5), placing the client at greatest risk for respiratory depression due to weak respiratory muscles. The other complications are risks but less immediate.
Question 3 of 5
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.
Question 4 of 5
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
Question 5 of 5
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include:
Correct Answer: D
Rationale: S1 and S2 in an infant with coarctation of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the left upper sternal border. A diastolic murmur is not associated with coarctation of the aorta. Pulse pressure differences of >20 mm Hg exist between the upper extremities and the lower extremities. It is important to evaluate the upper and lower extremities with the appropriate-sized cuffs. Femoral and pedal pulses will be diminished or absent in infants with coarctation of the aorta.