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NCLEX RN· Full Length · NCLEX-RN Practice Test

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Showing all 10 practice questions with expert explanatory rationales.

Question 1 of 10

A client is being discharged after lithotripsy for removal of a kidney stone. Which statement by the client indicates understanding of the nurse's instructions?

A. I'll need to strain my urine the first thing in the morning.'

B. I will need to save all urine for the next 2 days and take it to the laboratory to be examined and strained.'

C. I will be careful to strain all the urine and save the stone.'

D. I won't need to strain my urine now that the procedure is complete.'

Expert Explanatory Rationale

Correct Answer: I will be careful to strain all the urine and save the stone.'

Post-lithotripsy, clients must strain all urine to catch stone fragments for analysis. Saving all urine or straining only in the morning is incorrect, and straining is still required.

Question 2 of 10

A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, 'How does this drug work?' What is the nurse's best response?

A. It blocks histamine, reducing the allergic response.'

B. It inhibits the enzyme responsible for bile excretion.'

C. It decreases the amount of bile in the gallbladder.'

D. It binds with bile acids and is excreted in bowel movements with stool.'

Expert Explanatory Rationale

Correct Answer: It binds with bile acids and is excreted in bowel movements with stool.'

Cholestyramine binds bile acids in the intestine, forming a complex excreted in stool, reducing circulating bile acids that cause itching in obstructive jaundice.

Question 3 of 10

The nurse is administering a mantoux test. Which is a part of the correct technique for administering this test?

A. Administer IM in the deltoid muscle

B. Deposit the PPD subcutaneously in the upper arm

C. Deposit the PPD subcutaneously with the needle bevel up

D. Give the test subcutaneously in the inner aspect of the forearm using a 1Ã‚Â½-inch needle

Expert Explanatory Rationale

Correct Answer: Deposit the PPD subcutaneously with the needle bevel up

The Mantoux test is administered intradermally (not subcutaneously) in the inner forearm with the needle bevel up to create a wheal, ensuring accurate delivery of PPD.

Question 4 of 10

The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor?

A. Impaired gas exchange related to hyperventilation

B. Alteration in placental perfusion related to maternal position

C. Impaired physical mobility related to fetal-monitoring equipment

D. Potential fluid volume deficit related to decreased fluid intake

Expert Explanatory Rationale

Correct Answer: Potential fluid volume deficit related to decreased fluid intake

Decreased fluid intake during the latent phase can lead to dehydration, making fluid volume deficit a priority.

Question 5 of 10

A nurse is leading a parenting class for new parents. She explains that most babies say their first word by age

A. 6 months.

B. 12 months.

C. 10 months.

D. 18 months.

Expert Explanatory Rationale

Correct Answer: 12 months.

Most babies say their first word around 12 months, aligning with developmental milestones for language.

Question 6 of 10

The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents:

A. That the infant will need daily calcium supplements

B. That it is best to lift the infant by the buttocks when diapering

C. That the condition is a temporary one

D. That only the bones of the infant are affected by the disease

Expert Explanatory Rationale

Correct Answer: That it is best to lift the infant by the buttocks when diapering

Osteogenesis imperfecta is a genetic disorder causing brittle bones; lifting by the buttocks reduces the risk of fractures during diapering.

Question 7 of 10

The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?

A. Two finger widths are noted between the axilla and the top of the crutch.

B. The client bears weight on his hands when ambulating.

C. The crutches and the client's feet move alternately.

D. The client bears weight on his axilla when standing.

Expert Explanatory Rationale

Correct Answer: The client bears weight on his axilla when standing.

Bearing weight on the axilla can cause nerve damage; crutches should be used with weight on the hands, and two finger widths of clearance is correct.

Question 8 of 10

A tornado touched down in a large community, and the hospital is anticipating many casualties will be sent to the facility within the next few hours. The nurse should first

A. activate the emergency disaster response plan.

B. obtain any extra supplies from the supply closet.

C. prepare a triage staging area.

D. call in extra staff, even if they are not scheduled to work.

Expert Explanatory Rationale

Correct Answer: activate the emergency disaster response plan.

Activating the emergency disaster response plan is the priority to coordinate resources, staff, and triage, ensuring an organized response to mass casualties.

Question 9 of 10

The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

A. Assess the client for allergies

B. Bolus the client with IV fluid

C. Tell the client he will be asleep

D. Insert a urinary catheter

Expert Explanatory Rationale

Correct Answer: Assess the client for allergies

Assessing for allergies, particularly to iodine or contrast agents, is essential before a thyroid scan to prevent adverse reactions.

Question 10 of 10

Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching?

A. I must flush the tube with water after feedings and clamp the tube.

B. I must check placement four times per day.

C. I will report to the doctor any signs of indigestion.

D. If my father is unable to swallow, I will discontinue the feeding and call the clinic.

Expert Explanatory Rationale

Correct Answer: I must flush the tube with water after feedings and clamp the tube.

Flushing and clamping the PEG tube after feedings prevents clogging and ensures patency.

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