NCLEX-RN
Best NCLEX RN Question Bank Questions
Extract:
Question 1 of 5
You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
Question 2 of 5
A nurse who fails to check a client's armband before administering his medications is:
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.
Question 3 of 5
You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?
Correct Answer: D
Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.
Question 4 of 5
A client who had a total knee replacement with a metal prosthesis is being prepared for discharge to home. Which statement by the client indicates to the nurse a need for further teaching?
Correct Answer: A
Rationale: After a total knee replacement, the client should be taught to report any changes in the shape of the knee. This is not an expected event during recuperation from surgery. The client must notify caregivers of the metal implant because the client will need antibiotic prophylaxis for invasive procedures, and will be ineligible for magnetic resonance imaging as a diagnostic procedure. With a metal prosthesis, the client must be on anticoagulant therapy and should report adverse effects of this therapy, such as evidence of bleeding from a variety of sources. Fever, redness, or increased pain may indicate infection.
Question 5 of 5
A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client?
Correct Answer: D
Rationale: The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature.