NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). The nurse should give priority to:
Correct Answer: A
Rationale: COPD impairs gas exchange, so monitoring oxygen saturation is critical to assess respiratory function and guide oxygen therapy.
Question 2 of 5
A client with a C-34 fracture has just arrived in the emergency room. The primary nursing intervention is:
Correct Answer: B
Rationale: If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. Primary intervention is protection of the airway and adequate ventilation. All other interventions are secondary to adequate ventilation.
Question 3 of 5
A client with HELLP syndrome is admitted to the labor and delivery unit for observation. The nurse knows that the client will have elevated:
Correct Answer: B
Rationale: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is characterized by elevated liver enzymes, reflecting liver dysfunction.
Question 4 of 5
The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
Correct Answer: C
Rationale: Head measurement (e.g., head circumference) is the most objective for hydrocephalus, directly assessing skull enlargement. Anorexia (
A), vomiting (
B), and temperature (
D) are subjective or less specific.
Question 5 of 5
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?
Correct Answer: B
Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.