NCLEX Questions, NCLEX RN Nursing Exam Questions, NCLEX-RN Q

Extract:

Question 1 of 5

The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?

Correct Answer: B

Rationale:
Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.

Question 2 of 5

A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:

A. Deep depression B. Psychotic depression C. Severe anxiety D. Severe depression

Correct Answer: D

Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.

Question 3 of 5

A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery:

A. Takes more time to remove B. Has a greater risk of becoming reoccluded C. Is smaller in diameter D. Has too many valves

Correct Answer: A

Rationale: It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it.

Question 4 of 5

An 83-year-old client has been hospitalized following a fall in his home. He has developed a possible fecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction?

A. Boardlike, rigid abdomen B. Loss of the urge to defecate C. Liquid stool D. Abdominal pain

Correct Answer: C

Rationale: Liquid stool can pass around an impaction, making it a key indicator. The other findings are not specific to fecal impaction.

Question 5 of 5

A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:

A. Adhering to a strict schedule of diet, exercise, and wound care B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center D. Allowing him to plan, assist in, and perform his own care whenever possible

Correct Answer: D

Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.