NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Correct Answer: A
Rationale: Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). Approaching a client in a challenging manner is threatening and inappropriate. A non-challenging and calm approach reflects staff in control and may increase client's internal control. It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
Question 2 of 5
The client is admitted with a diagnosis of septic shock. Which intervention is the priority?
Correct Answer: A
Rationale: In septic shock, administering IV antibiotics within the first hour is the priority to target the infection causing shock. Vasopressors, catheterization, and cultures are secondary.
Question 3 of 5
Which statement is true regarding therapy with Levemir (insulin detemir)?
Correct Answer: D
Rationale: Levemir (insulin detemir) is a long-acting insulin with a duration of up to 24 hours, used for basal coverage. Its onset is 1–2 hours, but it has no distinct peak, and it should not be mixed with other insulins.
Question 4 of 5
A client with a history of a stroke is being taught to use a communication board. The nurse should:
Correct Answer: C
Rationale: Placing the communication board on the client’s strong side facilitates use, especially with hemiplegia. Loud speech, complex sentences, and limiting gestures are unhelpful.
Question 5 of 5
A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava-kava:
Correct Answer: A
Rationale: Kava-kava can potentiate the effects of anesthesia and analgesics, increasing the risk of excessive sedation or respiratory depression, necessitating physician awareness.