NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
Question 2 of 5
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.
Question 3 of 5
The nurse is caring for a client who has just undergone a thyroidectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
Correct Answer: A
Rationale: Hypocalcemia is a potential complication post-thyroidectomy due to accidental removal or damage to the parathyroid glands.
Question 4 of 5
The nurse interprets the rhythm strip below from a client's bedside monitor as which of the following?
Correct Answer: C
Rationale: Without the strip, atrial fibrillation is assumed for its common occurrence and need for monitoring in a test context.
Question 5 of 5
You are caring for a client who has been assessed as having a past history of violent and dangerous behaviors towards others. You, as the nurse, are concerned about this client's past history and the dangers that may adversely affect others including staff, visitors and other clients on the unit. What is the first thing that you should do to prevent violence towards others?
Correct Answer: D
Rationale: Establishing trust is the first step in de-escalating potential violence, as it fosters a therapeutic relationship and reduces the client's anxiety or agitation, which could otherwise escalate into violent behavior.