NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a colostomy. Which finding requires immediate intervention?
Correct Answer: D
Rationale: A significantly protruding stoma may indicate prolapse, a complication requiring immediate intervention to prevent ischemia or obstruction. Pink stoma, cramping, and liquid stool are normal or less urgent.
Question 2 of 5
Nursing care of the infant prior to surgical closure of a meningomyelocele would include:
Correct Answer: B
Rationale: A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying.
Question 3 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 4 of 5
The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:
Correct Answer: C
Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.
Question 5 of 5
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?
Correct Answer: A
Rationale: Relief of pain is the primary goal of nursing intervention because this client is experiencing acute pain. Fluid volume deficit is being treated with IV fluid replacement. Knowledge deficit will not be addressed at this time because a client in acute pain is not ready to learn. Alteration in nutrition is the third priority after relief of pain and fluid volume deficit.