NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
Question 2 of 5
You are providing care to a permanently disabled Iraqi war veteran who is 28 years of age. When he returned home from the war at the age of years of age 2 years ago he was deemed permanently disabled by both the Veterans Administration (VA) and the Social Security Administration. He receives a substantial monthly service connected disability check from the Veterans Administration and he has no spouse or legal dependents. Which type of governmental health insurance is he now entitled to?
Correct Answer: B
Rationale: Individuals deemed permanently disabled by the Social Security Administration for at least 24 months are eligible for Medicare, regardless of age . The veteran is also eligible for VA healthcare, but option A incorrectly states 'only' VA services. Medicaid eligibility depends on income and state criteria, which are not confirmed here.
Question 3 of 5
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
Question 4 of 5
The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?
Correct Answer: B
Rationale: The parent should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the primary health care provider or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the parent after surgery so that he or she will be familiar with their appearance. The remaining options are incorrect.
Question 5 of 5
The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.