NCLEX RN· Full Length · NCLEX RN Nursing Exam
Full Question & Rationale Repository
Showing all 10 practice questions with expert explanatory rationales.
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
Expert Explanatory Rationale
Correct Answer: Provide activities to foster her self-identity
The nurse is caring for a client with a diagnosis of abruptio placenta. Which nursing intervention is most appropriate?
Expert Explanatory Rationale
Correct Answer: Monitor fetal heart tones
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
Expert Explanatory Rationale
Correct Answer: Wound culture results showing minimal bacteria
A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with:
Expert Explanatory Rationale
Correct Answer: Pulmonary contusions
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?
Expert Explanatory Rationale
Correct Answer:
On the third postpartum day, the nurse would expect the lochia to be:
Expert Explanatory Rationale
Correct Answer: Rubra
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
Expert Explanatory Rationale
Correct Answer: Straining of all urine
The family member of a child scheduled for heart surgery states, 'I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?' The nurse explains that patent ductus arteriosus repair is:
Expert Explanatory Rationale
Correct Answer: Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which laboratory value is most likely to be elevated?
Expert Explanatory Rationale
Correct Answer: Human chorionic gonadotropin (hCG)
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
Expert Explanatory Rationale
Correct Answer: Diminished breath sounds on the affected side