NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks at the nurse and says, 'My life is so bad no one can do anything to help me.' The most helpful initial response by the nurse would be:
Correct Answer: C
Rationale: This response does not acknowledge the client's feelings and may increase his feelings of guilt. This response denotes false reassurance. This response acknowledges the client's feelings and invites a response. This response changes the subject and does not allow the client to talk about his feelings.
Question 2 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 3 of 5
Loss of appetite for a child with leukemia is a major recurrent problem. The plan of care should be designed to:
Correct Answer: A
Rationale: Ignoring refusals to eat and rewarding eating attempts are the most successful means of increasing intake. This goal is not specific enough or related to the loss of appetite. This goal is not possible at this time based on his illness. This goal is helpful, but alone will not address his loss of appetite.
Question 4 of 5
A client being treated with sodium warfarin (Coumadin) has a prothrombin time of 120 seconds. The nurse recognizes that:
Correct Answer: A
Rationale: A prothrombin time of 120 seconds is excessively prolonged indicating a high bleeding risk. Close monitoring for bleeding (e.g. bruising hematuria) is critical. The dosage is not inadequate vitamin K restriction is routine and doubling doses is dangerous.
Question 5 of 5
The initial treatment for a client with a liquid chemical burn injury is to:
Correct Answer: B
Rationale: The use of large amounts of water to flush the area is recommended for chemical burns to dilute and remove the chemical. Neutralizing solutions may extend the burn, calcium chloride is not indicated, and lanolin is not beneficial initially.