NCLEX RN Practice Exam
Question 1 of 5.
A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
A. Decreased cardiac output related to damage to the myocardium
B. Impaired tissue perfusion related to an occlusion in the coronary vessels
C. Acute pain related to cardiac ischemia
D. Ineffective breathing patterns related to decreased oxygen to the tissues
Explanation: Impaired tissue perfusion due to coronary occlusion is the primary cause of acute myocardial infarction.
Question 2 of 5.
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
A. Counseling regarding problems of body image.
B. Maintain airborne precautions.
C. Maintain aseptic technique during procedures.
D. Encourage peers to visit on a regular basis.
Explanation: safety is a priority for the client who is at high risk for infection
Question 3 of 5.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
A. Interpret the grieving process for the parents.
B. Discuss the reality of institutional placement.
C. Assist the parents in making decisions and long-term plans for the child.
D. Perform a family assessment to assist in the planning of intervention.
Explanation: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
Question 4 of 5.
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
A. Perform passive range-of-motion exercises before walking.
B. Encourage partial weight bearing while ambulating.
C. Immobilize the extremity between activities.
D. Restrict the amount of time and the distance the man walks.
Explanation: would relieve weight, pressure, and stress on affected leg, may use walker
Question 5 of 5.
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations are expected with scoliosis?
A. The girl’s thoracic area is asymmetrical.
B. The girl walks with a waddling gait.
C. The girl’s lower legs are edematous.
D. The girl has a protruding sternum.
Explanation: thoracic area becomes noticeably distorted