NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is caring for a client following a Whipple procedure. The nurse should give priority to assessing for:
Correct Answer: B
Rationale: The Whipple procedure involves pancreatic resection, increasing the risk of hypoglycemia due to altered insulin production, making this a priority assessment.
Question 2 of 5
A female client has been diagnosed with chronic renal failure. She is a candidate for either peritoneal dialysis or hemodialysis and must make a choice between the two. Which information should the nurse give her to help her decide?
Correct Answer: A
Rationale: Hemodialysis is faster in clearing the blood of toxins than peritoneal dialysis. However, clients must consider the time that they spend traveling to the dialysis center and the disruption in their daily lives. Peritoneal dialysis requires several exchanges with dwelling time for the dialysate and therefore takes longer than hemodialysis. Several serious complications of peritoneal dialysis include peritonitis, catheter displacement and/or plugging, or pain during dialysis. A client can be taught to self-administer peritoneal dialysis without the aid of a professional.
Question 3 of 5
The nurse is caring for a client with a history of multiple sclerosis. Which intervention is most appropriate to prevent complications?
Correct Answer: C
Rationale: Hot baths can exacerbate multiple sclerosis symptoms by increasing body temperature, causing fatigue or weakness. Weight-bearing exercise is encouraged, antibiotics are not routine, and fluid restriction is harmful.
Question 4 of 5
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record:
Correct Answer: C
Rationale: G=3 (current pregnancy), T=1 (term birth), P=1 (preterm birth), A=0 (no abortions), L=2 (living children).
Question 5 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.