NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
Which statement is true regarding a patient with a Sengstaken-Blakemore tube?
Correct Answer: D
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding. Scissors must be kept at the bedside to cut the tube in case of airway obstruction from balloon migration. The gastric balloon (not esophageal) controls bleeding the tube has three lumens and esophageal balloon pressure is typically 20-25 mmHg.
Question 2 of 5
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
Correct Answer: A
Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.
Question 3 of 5
A client with a history of bipolar disorder is prescribed lithium. Which laboratory value should the nurse monitor closely?
Correct Answer: C
Rationale: Lithium requires monitoring of serum lithium levels to ensure therapeutic range (0.6–1.2 mEq/L) and prevent toxicity. Sodium (
A), BUN (
B), and A1c (
D) are secondary.
Question 4 of 5
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
Correct Answer: B
Rationale: This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. This answer is correct. The nurse should appropriately present reality. This answer is incorrect. Showing interest would reinforce the delusional system. This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
Question 5 of 5
The client is admitted with a diagnosis of hypoparathyroidism. Which electrolyte imbalance is the client at risk for?
Correct Answer: C
Rationale: Hypoparathyroidism reduces parathyroid hormone, decreasing calcium levels and causing hypocalcemia. Potassium, hypercalcemia, and hypermagnesemia are not directly related.