NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
Correct Answer: A
Rationale: Ménière’s disease affects the inner ear, causing vertigo, tinnitus, and hearing loss due to fluid imbalance.
Question 2 of 5
A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?
Correct Answer: C
Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.
Question 3 of 5
The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
Correct Answer: A
Rationale: Esomeprazole (Nexium) a proton pump inhibitor is most effective when taken 30 minutes before breakfast to suppress acid production before meals. Taking it with or after meals or at bedtime is less optimal for gastritis treatment.
Question 4 of 5
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
Correct Answer: A
Rationale: A full bladder would cause discomfort and possible urinary incontinence during the exam. The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. Arms extended over the head would cause the abdomen to be tighter and less easily palpable. Forcing fluids would encourage a full bladder, which is not desired for the exam.
Question 5 of 5
A male client seeks counseling after his wife of 19 years threatened to divorce him. For most of their marriage, he has physically and verbally abused her. When asked about his behavior in the process of the nursing assessment, the client states, 'I was mean to my wife because she insists on cooking meals and wearing clothes that I do not like.' This defense mechanism is an example of:
Correct Answer: D
Rationale: Repression is blocking a desire from conscious expression. The client is conscious of his desires. Regression is returning to an earlier form of expression, which is not demonstrated here. Reaction formation is acting out the opposite of true feelings. The client felt anger concerning his wife's cooking and acted out his feelings. Rationalization is unconsciously falsifying an experience by giving a 'rational' explanation. The client is attempting to justify his behavior by giving an explanation.