NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT?
Correct Answer: A
Rationale: A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases.
Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated.
Question 2 of 5
A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate?
Correct Answer: A
Rationale: The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. The child may express discomfort verbally and should be encouraged to express his feelings. Selecting nonthreatening words to explain a procedure will prevent misinterpretation. When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
Question 3 of 5
Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?
Correct Answer: D
Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.
Question 4 of 5
A client is admitted to the hospital in chronic renal failure. A low protein diet is ordered. The rationale for a low protein diet is that:
Correct Answer: A
Rationale: In chronic renal failure, a low protein diet reduces the production of nitrogenous wastes like blood urea nitrogen (BUN), easing the kidneys’ workload. It does not directly affect sodium, potassium, albumin, calcium, or phosphorus levels.
Question 5 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.