NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client's room?
Correct Answer: D
Rationale: Diazepam is a benzodiazepine and has sedative/hypnotic effects with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse raises a side rail on the bed and instructs the client not to get out of bed without assistance. Note that agency policy regarding the use of side rails is always followed. Although the remaining options may be helpful measures that provide a comfortable, restful environment, instructing the client to ask for assistance when getting out of bed provides for the client's safety needs.
Question 2 of 5
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
Question 3 of 5
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.
Question 4 of 5
A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?
Correct Answer: D
Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.
Question 5 of 5
The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply.
Correct Answer: A,C,D
Rationale: Ototoxicity affecting the vestibular branch causes vertigo, nausea, and ataxia due to balance disruption. Tinnitus and hearing loss are associated with cochlear branch damage.