NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
Question 2 of 5
The client is receiving a blood transfusion. Which finding indicates a possible transfusion reaction?
Correct Answer: D
Rationale: Itching and rash are signs of a possible allergic transfusion reaction, requiring immediate cessation of the transfusion. A slight temperature increase, mild hypotension, or tachypnea may occur but are less specific without other symptoms.
Question 3 of 5
A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:
Correct Answer: A
Rationale: Heavy lifting increases abdominal pressure, worsening hiatal hernia symptoms. Small meals, sleeping upright, and avoiding spicy foods are also recommended.
Question 4 of 5
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest?
Correct Answer: A
Rationale: Increased locomotive skills make push-pull toys appropriate for the energetic toddler. Infants progress from reflex activity through simple repetitive behaviors to imitative behavior. Hand-eye coordination forms the foundation of other movements. At age 8 months, infants begin to have pincer grasp.
Toys that help infants develop the pincer grasp are recommended for this age group. Various large colored blocks are suggested toys for infants 6-12 months of age to help visual stimulation.
Question 5 of 5
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.