NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
Question 2 of 5
A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
Question 3 of 5
A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason?
Correct Answer: A
Rationale: Lipids are a brand of intravenous fat emulsion administered to clients who are at risk for developing an essential fatty acid deficiency, such as those receiving TPN. Fat emulsions help meet caloric and nutritional needs that cannot be met by glucose administration alone. Fat emulsions are not administered to increase the amount of body fluids and they do not decrease the incidence of phlebitis. Fat emulsions neither replace TPN nor do they require infusion during the night.
Question 4 of 5
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
Question 5 of 5
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.