NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
The nurse is developing a plan of care for a client with an electrolyte imbalance and identifies a nursing diagnosis of decreased physical mobility. Which alteration is most likely the etiology?
Correct Answer: C
Rationale: A deficit in sodium concentration results in muscular weakness and lethargy. Muscle fatigue and hypotonia are caused by hypercalcemia. Muscle weakness and fatigue are classic signs of hypokalemia. Hypermagnesemia can cause muscle weakness, paralysis, and coma.
Question 2 of 5
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
Correct Answer: D
Rationale: A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
Question 3 of 5
The nurse is teaching a client with a history of celiac disease about dietary modifications. The nurse should tell the client to avoid:
Correct Answer: A
Rationale: Celiac disease requires a gluten-free diet to prevent intestinal damage, so avoiding gluten-containing foods is essential.
Question 4 of 5
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following:
Correct Answer: C
Rationale: This statement describes a normal assessment finding of the lower extremities. This assessment finding reflects problems caused by venous insufficiency. Decreased or absent pedal pulses reflect a problem caused by arterial insufficiency. The leg that is experiencing arterial insufficiency would be cool to touch due to the decreased circulation.
Question 5 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.