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 is caring for a client with a diagnosis of molar pregnancy. Which complication is most likely to occur?
Correct Answer: A
Rationale: Molar pregnancy can progress to choriocarcinoma a malignant tumor in rare cases. Fetal distress and preterm labor are not risks as there is no viable fetus and hypoglycemia is unrelated.
Question 3 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.
Question 4 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 5 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.