NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
The nurse is teaching the mother of an infant with galactosemia. Which information should be included in the nurse's teaching?
Correct Answer: A
Rationale: Galactosemia requires a lactose-free diet, as galactose is harmful. Checking labels for lactose is critical. Galactose cannot be added, siblings may be affected, and galactose is not essential.
Question 2 of 5
A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Using an electric razor prevents the risk of cuts while shaving. Any physician or dentist should be informed of anticoagulant therapy because of the risk of bleeding due to a prolonged PT. The client should be instructed to consult with his physician. Aspirin is avoided because it potentiates the effects of oral anticoagulants by interfering with platelet aggregation. Identification bracelets are necessary to direct treatment, especially in an emergency situation.
Question 3 of 5
A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority?
Correct Answer: D
Rationale: If changes in the FHR are noted, the nurse should check for umbilical cord prolapse. This intervention has priority over the other actions. The danger of a prolapsed cord is increased once membranes have ruptured, especially if the presenting part of the fetus does not fit firmly against the cervix.
Question 4 of 5
A schizophrenic client who is experiencing thoughts of having special powers states that 'I am a messenger from another planet and can rule the earth.' The nurse assesses this behavior as:
Correct Answer: D
Rationale: Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. Clients experiencing delusions of persecution believe that others in the environment are plotting against them. Clients experiencing thought broadcasting perceive that others can hear their thoughts. Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
Question 5 of 5
Nursing care for the parents of a child with a congenital heart defect would include:
Correct Answer: B
Rationale: It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. Anger and resentment are normal feelings that must be dealt with appropriately. Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'