NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following interventions should be included in the plan of care?
Correct Answer: A, C
Rationale: Early ambulation and leg elevation promote venous return and prevent clot progression. Cold compresses and massage are contraindicated.
Question 2 of 5
A client with a history of gout is admitted with joint swelling. The nurse should include which of the following in the plan of care?
Correct Answer: C
Rationale: Indomethacin reduces inflammation and pain in acute gout attacks.
Question 3 of 5
In preparing a plan of care, which is the priority intervention to address the needs of a client recently assaulted sexually?
Correct Answer: D
Rationale: After the provision of medical treatment, the nurse's next priority would be obtaining support and planning for safety. Option 1 is concerned with ensuring that the victim understands the importance of and commits to the need for medical follow-up. From the options provided, this is not a priority intervention. Options 2 and 3 seek to meet the emotional needs related to the rape and emotional readiness for the process of discovery and legal action.
Question 4 of 5
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
Question 5 of 5
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.