NCLEX-RN
Basic Adult Health Care NCLEX Questions Questions
Extract:
Question 1 of 5
A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, 'Why should I bother stretching my muscles? It doesn't seem to make any difference what I do.' The nurse responds by helping the client establish reasonable activity goals, choose their own health care from the menu, and make choices about her daily activities. These interventions represent the nurse's attempt to address which of the following nursing diagnoses?
Correct Answer: B
Rationale: The client's statement reflects powerlessness, and the nurse's interventions aim to restore a sense of control through goal-setting and decision-making.
Question 2 of 5
The client is scheduled to have an upper gastrointestinal tract series of x-rays. Following the x-rays, the nurse should instruct the client to:
Correct Answer: A
Rationale: A laxative is typically recommended after an upper GI series to help eliminate the barium used in the procedure and prevent constipation.
Question 3 of 5
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug?
Correct Answer: B,C,E
Rationale: Warfarin's maximum effect takes 3-4 days (
B), its effects persist 4-5 days after stopping (
C), and periodic blood tests (e.g., INR) are required (E). Peak action is not 2 hours, and protamine sulfate is the antidote for heparin, not warfarin.
Question 4 of 5
A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response?
Correct Answer: D
Rationale: A potassium level of 5.8 mEq/L indicates hyperkalemia, which can cause cardiac complications under general anesthesia. Notifying the anesthesiologist first ensures prompt evaluation and management to ensure patient safety.
Question 5 of 5
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
Correct Answer: D
Rationale: Activity intolerance related to fatigue (
D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (
A), self-care deficit (
B), and ineffective coping (
C) are less directly supported by the symptoms described.