1. The nurse in the psychiatric impassable. The nurse de-
emer- gency room assesses 4
clients. Which of the following
clients should the nurse see
FIRST?
1. A patient was raped 30 min-
utes ago and expresses
feelings of self-blame, anxiety,
and worthless- ness.
2. A patient indicates an intent
to kill himself and says he has
access to a gun.
3. A patient had a
miscarriage last evening and
is experiencing anger and
resentment.
4. A patient witnessed a child
stabbed to death 2 weeks ago
and is experi- encing anxiety.
2. The nurse in a small town is
called to a neighbor's house in
the middle of a blizzard. The
neighbor woman states she is in
the 39th week of ges- tation with
her second baby and has been
having contractions for sever-
al hours. The woman has been
un-
able to obtain assistance
because the roads are
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, NCLEX Sample Test 1 Questions with Actual Answers.
Strategy: "FIRST" indicates priority.
1) need to assess physical needs and examine
pa- tient; second patient to see
Strategy: Assess before implementing.
2) CORRECT— patient is at risk for self-harm;
client has intent and a way to carry out threat
1) priority is assessing if baby is crowning
3) allow client to verbalize feelings
2) priority is assessing if baby is crowning
4) allow client to verbalize feelings
3) labor is not the priority; nurse should
determine if the birth is imminent
4) CORRECT— baby will descend into
birth canal
termines that the woman is in the sec- and may crown, major responsibility in
second state
ond stage of labor. It is MOST of labor; support infant's head; apply slight
impor- pressure
tant for the nurse to take which of the to control delivery
following actions?
2/
54
, NCLEX Sample Test 1 Questions with Actual Answers.
1. Time the frequency of the
contrac- tions.
2. Assess the type of vaginal
dis- charge.
3. Monitor the strength of the
con- tractions.
4. Observe the perineum.
3. The nurse receives a call from
Strategy: "FIRST" indicates priority.
the emergency management
team that 50 victims will be 1) CORRECT— nurse must follow chain of
transported to the com-
hospital in 15 minutes by ambulance. mand
Which of the following actions should
nurse take 2) not the nurse's responsibility
the
1. Contact the nursing 3) must notify immediate supervisor about the
supervisor. call; disaster plans are hospital policies that
2. Tell the emergency
management detail how
team nurses are to perform duties
they will have to re-route 25 vic-
tims. that further teach- ing is
3. Activate the hospital's necessary if the client
disaster plan. states which of the
4. Inform the emergency following?"
department nurses they must
work overtime.
4. As a part of discharge teaching,
the nurse instructs a client
receiving citalopram (Celexa) 20
mg OD. The nurse determines
3/
54
, NCLEX Sample Test 1 Questions with Actual Answers.
4) not the responsibility or role of the nurse incorrect information.
1) Celexa is a selective serotonin reuptake
inhibitor (SSRI) used to treat depression
2) side ettects: mania, hypomania,
Strategy: "Further teaching is necessary" indicates insomnia, impo-
1. "This medication helps me with my tence, headache, and dry mouth
4/
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