NCLEX Questions, NCLEX RN Nursing Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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NCLEX-RN Test Bank

NCLEX RN Nursing Exam Questions

Extract:


Question 1 of 5

The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?

Correct Answer: B

Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.

Question 2 of 5

Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?

Correct Answer: C

Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (
C) assess for deterioration. Pain medication (
A), oxygen (
B), and Foley (
D) are secondary.

Question 3 of 5

Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?

Correct Answer: C

Rationale: Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse.

Question 4 of 5

The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:

Correct Answer: A

Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.

Question 5 of 5

A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:

Correct Answer: A

Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.

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