NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?
Correct Answer: D
Rationale: A calm, polite request to stop (
D) de-escalates the situation while reinforcing the rule. Other responses (A, B,
C) are confrontational and likely to escalate the client's agitation.
Question 2 of 5
The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?
Correct Answer: D
Rationale: Absence of stool post-cholecystectomy may indicate a complication like ileus or obstruction, requiring physician evaluation.
Question 3 of 5
Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.
Correct Answer: B,C,E
Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (
B), measuring urinary output (
C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (
A) and monitoring a transfusion (
D) require a nurse's assessment skills.
Question 4 of 5
A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
Correct Answer: C
Rationale: Diet history is less directly related to diagnosing a bowel obstruction compared to pain, vomiting characteristics, or abdominal distension, which are hallmark symptoms.
Question 5 of 5
The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?
Correct Answer: B
Rationale: itching and hives indicate an allergic reaction; stopping the transfusion and notifying the physician is the priority