NCLEX-RN
NCLEX RN Practice Questions
Extract:
Question 1 of 5
The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
Correct Answer: C
Rationale: RSS 3 indicates a client who responds quickly to commands only, matching the description, per the Ramsay Sedation Scale.
Question 2 of 5
The nurse is educating a couple about permanent methods of birth control. Vasectomy for the male is discussed. The nurse explains that which organ is cut or sealed off to prevent sperm from entering semen?
Correct Answer: C
Rationale: The **vas deferens** is cut or sealed during a vasectomy to prevent sperm from entering semen, ensuring sterility.
Question 3 of 5
A client is admitted to the chemical dependency unit for poly-drug abuse. The client states, 'I don't know why you are all so worried; I am in control. I don't have a problem.' Which defense mechanism is being utilized?
Correct Answer: D
Rationale: Denial is the defense mechanism where the client refuses to acknowledge the reality of their substance abuse problem, minimizing its severity.
Question 4 of 5
The nurse caring for a client with myasthenia gravis recognizes which of the following as the priority nursing diagnosis?
Correct Answer: C
Rationale: Myasthenia gravis causes muscle weakness, including respiratory muscles, making ineffective airway clearance the priority due to risk of respiratory failure.
Question 5 of 5
A 5-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of:
Correct Answer: D
Rationale: Trendelenburg sign is associated with congenital hip dysplasia, where the pelvis tilts downward on the unaffected side when the child stands on the affected leg, indicating hip instability.