NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is preparing to administer a dose of lorazepam (Ativan) for anxiety. Which assessment is most important before administration?
Correct Answer: B
Rationale: Lorazepam, a benzodiazepine, can cause respiratory depression, so assessing respiratory rate is critical before administration. Other vital signs are monitored but are less specific.
Question 2 of 5
A 4-year-old child is being discharged from the hospital after being treated for severe croup. Which one of the following instructions should the nurse give to the child's mother for the home treatment of croup?
Correct Answer: A
Rationale: Initial home treatment of croup includes placing the child in an environment of high humidity to liquefy and mobilize secretions. Antihistamines should be avoided because they can cause thickening of secretions. Drooling is a characteristic sign of airway obstruction and the child should be taken directly to the emergency room. Crying increases respiratory distress and hypoxia in the child with croup. The nurse should promote methods that will calm the child.
Question 3 of 5
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, 'My doctor is in love with me and wants to marry me.' This client is using which of the following defense mechanisms?
Correct Answer: B
Rationale: Displacement involves transferring feelings to a more acceptable object. Projection involves attributing one's thoughts or feelings to another person. Reaction formation involves transforming an unacceptable impulse into the opposite behavior. Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
Question 4 of 5
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the nurse take?
Correct Answer: D
Rationale: This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery.
To increase O2 perfusion to the unborn infant, the mother should be placed on her left side. IV fluids should be increased, not decreased. Immediate action is warranted, such as reporting findings, turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate cesarean delivery, and explaining plan of action to client.
Question 5 of 5
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
Correct Answer: A
Rationale: This answer is correct. If the cause is removed, the delirious client will recover completely. This answer is incorrect. The demented client is incapable of returning to previous level of functioning. The delirious client is capable of returning to previous functioning. This answer is incorrect. The demented client, not the delirious client, has progressive intellectual and behavioral deterioration. This answer is incorrect. Delirium develops rapidly, whereas dementia is insidious.