NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is assessing the client with metabolic alkalosis. Which findings would likely be observed in this client?
Correct Answer: B, C, E, F
Rationale: Metabolic alkalosis results from excess bicarbonate or loss of acids (e.g., from vomiting). Vomiting and nausea (
C) are common causes. Numbness (
B), circumoral paresthesia (E), and hypertonic muscle contractions (F) occur due to hypocalcemia from alkalosis. Kussmaul’s respirations (
A) are associated with metabolic acidosis, and warm flushed skin (
D) is unrelated.
Question 2 of 5
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, 'Nobody in here seems to really care about the clients. I thought nurses cared about people!' The client is exhibiting the ego defense mechanism:
Correct Answer: C
Rationale: Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
Question 3 of 5
An adult client is admitted to the orthopedic unit with a history of thalassemia. What clinical manifestations does the nurse expect the client to exhibit?
Correct Answer: A, B, C
Rationale: Thalassemia causes splenomegaly (
A) from hemolysis, mild anemia (
B), and jaundice (
C) from bilirubin buildup. Headaches (
D) and epistaxis (E) are less common.
Question 4 of 5
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first?
Correct Answer: B
Rationale: When examining an infant, the nurse should start with the least invasive procedures to maintain the infant’s calm state. Listening to heart and lung sounds is non-invasive and can be done while the infant is quiet. Checking the Babinski reflex, palpating the abdomen, or checking tympanic membranes may cause discomfort and disrupt the exam.
Question 5 of 5
The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include:
Correct Answer: D
Rationale: Weight should be obtained daily. Fluid is not restricted but is given according to urine output. The medication does not have to be stored in a refrigerator. Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.