NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
In discussing the plan of care for a child with chronic nephrosis with the mother, the nurse identifies that the purpose of weighing the child is to:
Correct Answer: D
Rationale: Weighing a child with nephrosis is to assess for edema, not nutrition. (B,
C) This is not the purpose for weighing the child. Weight and measurement are the primary ways of evaluating edema and fluid shifts.
Question 2 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 3 of 5
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
Correct Answer: B
Rationale: The infant will be at risk for hypoglycemia because of excess insulin production.
Question 4 of 5
A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?
Correct Answer: C, E, F
Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.
Question 5 of 5
The nurse enters the room of a client on which a 'do not resuscitate' order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, 'please save her!' The nurse's action would be:
Correct Answer: D
Rationale: (A, B,
C) The last request from the husband overrides the decision not to initiate resuscitation efforts. The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.