NCLEX-RN Exam

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Question 1 of 5.

A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

A. Continue to monitor the foot

B. Notify the physician immediately

C. Reposition and reassess the foot

D. Assure the client that his foot is fine

Explanation: The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg.

Question 2 of 5.

After attending a company picnic, several clients are admitted to the emergency room with E. coli food poisoning. The most likely source of infection is:

A. Hamburger

B. Hot dog

C. Potato salad

D. Baked beans

Explanation: Undercooked hamburger is a common source of E. coli, particularly E. coli O157:H7, which can contaminate ground beef.

Question 3 of 5.

A client with paranoid schizophrenia is brought to the hospital by her elderly parents. During the assessment, the client's mother states, 'Sometimes she is more than we can manage.' Based on the mother's statement, the most appropriate nursing diagnosis is:

A. Ineffective family coping related to parental role conflict

B. Care-giver role strain related to chronic situational stress

C. Altered family process related to impaired social interaction

D. Altered parenting related to impaired growth and development

Explanation: The mother's statement reflects caregiver role strain due to the chronic stress of managing a child with paranoid schizophrenia, impacting the parents' ability to cope.

Question 4 of 5.

A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

A. Helping the client develop a plan for changing his behavior

B. Contracting with him for the time he spends on a task

C. Avoiding a discussion of his annoying behavior because it will only make him worse

D. Encouraging him to set a time schedule and deadlines for himself

Explanation: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.

Question 5 of 5.

The nurse has just received the change of shift report. Which client should the nurse assess first?

A. A client with a supratentorial tumor awaiting surgery

B. A client admitted with a suspected subdural hematoma

C. A client recently diagnosed with akinetic seizures

D. A client transferring to the neuro rehabilitation unit

Explanation: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.

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