Exam Cram NCLEX RN Practice 250 questions and Rationales Latest 2024/2025 with complete solution
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
A. 1 cup beef broth
B. 1 baked potato
C. 1/2 cup raisins
D. 1 cup rice Ans- D (1 cup of rice)
( Answer D is correct because one cup of rice is considered a low-potassium food. The foods in answer A,
B, and C are incorrect because they contain higher amounts of potassium)
An appropriate nursing intervention for the client with borderline personality disorder is:
A. Observing the client for signs of depression or suicidal thinking
B. Allowing the client to lead unit group sessions
C. Restricting the client's activity to the assigned unit of care throughout hospitalization
D. Allowing the client to select a primary caregiver Ans- A (observing the client for signs of depression or
suicidal thinking)
(Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect because the client's activities do
not have to be restricted to the unit after the level of depression has been determined )
Which of the following is an expected finding in the assessment of a client with bulimia nervosa
A. Extreme weight loss B. Presence of lanugo over body
C. Erosion of tooth enamel
D. Muscle wasting Ans- C (Erosion of tooth enamel)
(Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with
bulimia nervosa. Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.)
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
A. One-year-old
B. Four-year-old
C. Eight-year-old
D. Twelve-year-old Ans- B (Four-year-old)
(Because of their increased mobility, manual dexterity and curiosity, the four year old is at greater risk for accidental poisoning. Other accidental injuries in this age group include being struck by a car, falls, burns, and drowning. Answer A is incorrect because the one-year-old lacks the developmental skill to be at risk for accidental poisoning. Answers C and D are incorrect because the eight-year-old and the twelve-year-old are at less risk because they are aware of the dangers of accidental poisoning)
Which term describes the play activity of the preschool aged child?
A. Cooperative
B. Associative
C. Parallel
D. Solitary Ans- B (Associative)
(Play of the preschool aged child is described as associative. At this stage, children are more interested in playing with other children than they are with playing with toys. The child may talk to other children and exchange toys or play games without any rules. Answer A describes the play of a school-aged child. Answer C describes the play of an infant.)
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first? A. Check the Babinski reflex
B. Listen to the heart and lung sounds
C. Palpate the abdomen
D. Check tympanic membranes Ans- B (Listen to the heart and lung sounds)
(While the infant is quiet, the nurse should begin the exam by listening to the heart and lungs. If the nurse elicits the Babinski reflex , palpates the abdomen, or checks the tympanic membranes, the infant may cry and it will be difficult to adequately listen to the heart and lungs; therefore answers A,C, and D are incorrect.)
In terms of cognitive development, a three-year-old would be expected to:
A. Think abstractly
B. Use magical thinking
C. Understand conservation of matter
D. See things from the perspective of others Ans- B (Use magical thinking)
(A three-year-old is expected to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are incorrect because of abstract thinking, conservation of matter, and the ability to
look at things from the perspective of others are cognitive abilities of an older child)
Which of the following describes the language development of a two-year-old?
A. Doesn't understand yes and no
B. Understands the meaning of all words
C. Can combine three or four words
D. Repeatedly asks "why?" Ans- C (can combine three or four words)
(The two year old can combine three to four words. Answers A and B are incorrect because the two-
year-old understands yes and no, but does not understand the meaning of all the words. Answer D is incorrect because seeking information and asking "why?" is typical of the three-year old)
A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
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