NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
Question 2 of 5
Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?
Correct Answer: C
Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (
C) assess for deterioration. Pain medication (
A), oxygen (
B), and Foley (
D) are secondary.
Question 3 of 5
Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
Correct Answer: B
Rationale: Maternal diabetes increases the risk of neonatal respiratory distress syndrome due to impaired surfactant production from hyperglycemia. Alcohol, smoking, and hypertension are less directly linked.
Question 4 of 5
A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?
Correct Answer: A
Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.
Question 5 of 5
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
Correct Answer: C
Rationale: Skipping meals, like dinner, can cause hypoglycemia in patients on glyburide, a sulfonylurea that stimulates insulin release. Keeping candy for hypoglycemia, avoiding sun (due to photosensitivity), and wearing ID are correct.