NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (
A) to keep oil against the retina, head bowed when upright (
D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (
B) is not strict, and diet (
C) progresses as tolerated.
Question 2 of 5
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency. Replenishing every three months is not standard taking tablets every 15 minutes is incorrect (typically every 5 minutes up to 3 doses) and crushing is not appropriate.
Question 3 of 5
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question 4 of 5
A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family?
Correct Answer: D
Rationale: Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
Question 5 of 5
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
Correct Answer: C
Rationale: (A, B,
D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. Only regular insulin can be given IV.