NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
The physician recommends immediate hospital admission for a client with PIH. She says to the nurse, 'It's not so easy for me to just go right to the hospital like that.' After acknowledging her feelings, which of these approaches by the nurse would probably be best?
Correct Answer: B
Rationale: This answer does not hold the client accountable for her own health. The nurse should explore potential reasons for the client's anxiety: are there small children at home, is the husband out of town? The nurse should aid the client in seeking support or interventions to decrease the anxiety of hospitalization. Repeating the physician's reason for recommending hospitalization may not aid the client in dealing with her reasons for anxiety. The concern for self and welfare of baby may be secondary to a woman who is in a crisis situation. The nurse should explore the client's potential reasons for anxiety. For example, is there another child in the home who is ill, or is there a husband who is overseas and not able to return on short notice?
Question 2 of 5
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?
Correct Answer: B
Rationale: Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question 3 of 5
A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:
Correct Answer: A
Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.
Question 4 of 5
The nurse is caring for a postoperative client when the client becomes nonresponsive and pale,with a BP of 90/40. The nurse recognizes that the necessary intervention at this time is to:
Correct Answer: B
Rationale: Hypotension (BP 90/40) pallor,and nonresponsiveness suggest hypovolemic shock likely from postoperative bleeding. Increasing the IV infusion rate (e.g. saline) restores volume. Trendelenburg is controversial atropine treats bradycardia,and the emergency cart is secondary to immediate fluid resuscitation.
Question 5 of 5
The nurse is caring for a client with a history of atrial fibrillation. Which finding requires immediate intervention?
Correct Answer: C
Rationale: Dizziness and syncope in atrial fibrillation suggest hemodynamic instability, possibly from rapid ventricular response, requiring immediate intervention. Mild tachycardia, normal BP, and saturation are less urgent.