NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The client is diagnosed with hyperkalemia. Which food should the nurse instruct the client to avoid?
Correct Answer: A
Rationale: Bananas are high in potassium, which should be avoided in hyperkalemia to prevent worsening arrhythmias. Broccoli, salmon, and pasta have lower potassium content.
Question 2 of 5
A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
Correct Answer: B
Rationale: This statement is entirely false. Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. Although the cause of phantom pain is still unknown, these measures may promote the relief of any type of pain, not just phantom pain. Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
Question 3 of 5
Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?
Correct Answer: C
Rationale: Sickle cell anemia increases dehydration risk due to impaired blood flow, especially in heat. Extra fluids in summer prevent crises. Pain is due to vaso-occlusion, not excess RBCs, and skiing poses risks.
Question 4 of 5
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
Correct Answer: D
Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
Question 5 of 5
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
Correct Answer: D
Rationale: (A, B,
C) These answers are all correct; however, maintenance of airway is the top priority. Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.