NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced?
Correct Answer: C
Rationale: The description of the seizure, with the entire body becoming rigid (tonic phase) followed by alternating relaxation and contraction of muscles in all four extremities (clonic phase), is characteristic of a tonic-clonic seizure. Partial seizures involve only a portion of the body or brain, absence seizures are brief lapses in awareness without significant motor activity, and complex partial seizures involve altered consciousness with automatisms, none of which match the described symptoms.
Question 2 of 5
The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
Correct Answer: D
Rationale: Sitting forward with arms supported allows optimal access to the pleural space and ensures client comfort during thoracentesis.
Question 3 of 5
The nurse is caring for a client with a new colostomy. Which statement by the client indicates a need for further teaching?
Correct Answer: B
Rationale: High-fiber foods may cause blockages in a new colostomy. The client should start with a low-residue diet and gradually introduce fiber, indicating a need for further teaching.
Question 4 of 5
A client with a diagnosis of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity?
Correct Answer: B
Rationale: Yellow vision is a classic sign of digoxin toxicity, indicating the need for immediate evaluation.
Question 5 of 5
A college student is asking the nurse about his grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if he will have the disease, too. What should the nurse tell the student? Select all that apply.
Correct Answer: B,C
Rationale: Huntington's disease is an autosomal dominant disorder, meaning a 50% chance of inheritance if one parent is affected, and it typically does not skip generations. It affects men and women equally, is not treatable (only symptom management is available), and the risk is not 75% but 50%.