NCLEX Questions, Mock NCLEX RN Exam Questions, NCLEX-RN Ques

Extract:

Question 1 of 5

Place in sequence from 1-5 the proper order for introducing items to the infant's diet.

Correct Answer: C, D, E, A, B

Rationale: Infant diet sequence: rice cereal (
C) at 6 months, then fruits (
D) and vegetables (E), strained meats (
A) around 7-8 months, and whole milk (
B) after 12 months.

Question 2 of 5

The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?

A. Steamed broccoli B. Wheat toast C. Chocolate chip cookie D. Bran cereal

Correct Answer: A

Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (
B), chocolate chip cookies (
C), and bran cereal (
D) contain gluten.

Question 3 of 5

The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by:

A. Notifying the physician B. Changing the client to the left lateral position C. Continuing to monitor the FHR closely D. Administering O2 at 8 L/min via face mask

Correct Answer: C

Rationale: Early decelerations are reassuring and do not warrant notification of the physician. Because early decelerations is a reassuring pattern, it would not be necessary to change the client's position. Early decelerations warrant the continuation of close FHR monitoring to distinguish them from more ominous signs. O2 is not warranted in this situation, but it is warranted in situations involving variable and/or late decelerations.

Question 4 of 5

The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:

A. Blowing air under the cast using a hair dryer on cool setting often relieves itching. B. Slide a ruler under the cast and scratch the area. C. Guide a towel under and through the cast and move it back and forth to relieve the itch. D. Gently thump on cast to dislodge dried skin that causes the itching.

Correct Answer: A

Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.

Question 5 of 5

A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:

A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur D. Using distraction to help control the client's hyperventilation episodes

Correct Answer: C

Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.