NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
The client is admitted with a diagnosis of chorioamnionitis. Which vital sign change is most likely to be observed?
Correct Answer: D
Rationale: Chorioamnionitis causes maternal fever (from infection) tachycardia (from systemic response) and fetal bradycardia (from distress). All vital sign changes are likely in this condition.
Question 2 of 5
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
Question 3 of 5
A child has a nursing diagnosis of fluid volume excess related to compromised regulatory mechanisms. Which of the following nursing interventions is the most accurate measure to include in his care?
Correct Answer: A
Rationale: Although all of these interventions are important aspects of care, weight is the most sensitive indicator of fluid balance. Although monitoring intake and output is important, weight is a more accurate indicator of fluid status. Urine specific gravity does not necessarily indicate fluid volume excess. Edema may not be apparent, yet the client may have fluid volume excess.
Question 4 of 5
A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
Question 5 of 5
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to 'having a few drinks now and then.' He is probably experiencing which of the following?
Correct Answer: B
Rationale: Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.