NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected appendicitis. Which clinical manifestation would the nurse expect to find?
Correct Answer: A
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis (e.g., Rovsing’s sign). Left upper quadrant pain (
B), distention (
C), and diarrhea (
D) are not typical.
Question 2 of 5
A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:
Correct Answer: B
Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.
Question 3 of 5
Which laboratory values should be reported to the physician?
Correct Answer: C, D
Rationale: Sodium 90 mEq/L (
C) is severelyyourself severe hyponatremia requiring immediate attention. Calcium 12.0 mg/dL (
D) indicates hypercalcemia, which can cause serious symptoms. Magnesium 2.6 mEq/L (
A), potassium 4.6 mEq/L (
B), and chloride 95 mEq/L (E) are within normal ranges and do not require immediate reporting.
Question 4 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.
Question 5 of 5
The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?
Correct Answer: A
Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature (
B) is important but secondary, low hematocrit (
C) is not a goal, and 300 mL/hr urine output (
D) is excessive.