अन्तर्राष्ट्रिय नर्सिङ लाइसेन्स NCLEX-RN, DHA, HAAD र CBT तयारी
अन्तर्राष्ट्रिय नर्सिङ लाइसेन्स – NCLEX-RN, DHA, HAAD र CBT
NCLEX-RN / DHA / HAAD · NCLEX-RN / DHA / HAAD / CBT
२,०४४ प्रश्न उपलब्ध। मोड छान्नुहोस्:
अन्तर्राष्ट्रिय नर्सिङ: प्रश्न र उत्तर
सही लागेको विकल्पमा थिच्नुहोस्। सही भए हरियो, गलत भए रातो देखिन्छ; ३ सेकेन्डपछि सही उत्तर र व्याख्या देखिन्छ।
सही: ० / ०
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A client diagnosed with chronic obstructive pulmonary disease (COPD) is experiencing severe shortness of breath. The nurse observes that the client’s accessory muscles are visibly engaged during breathing. What nursing intervention would be MOST appropriate to immediately alleviate some of the client’s distress?
सही उत्तर: घ) Administer bronchodilator medication as prescribed.
Option 3 is correct. Positioning the patient in a prone position elevates the diaphragm and improves lung expansion, facilitating easier breathing for someone with COPD experiencing accessory muscle use. Options 1 and 2 are important long-term management strategies but don’t immediately address acute distress. Option 4 requires medication orders.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client recovering from an open-heart surgery is being discharged home with instructions to monitor their potassium levels regularly. The nurse understands that potassium imbalances can significantly affect cardiac function. Which electrolyte level would require IMMEDIATE notification of the physician?
सही उत्तर: ख) Potassium 4.2 mEq/L
Option 1 is correct. A potassium level of 4.2 mEq/L is above the normal range and, when combined with the client's recent surgery and potential for cardiac arrhythmias, warrants immediate physician notification due to the risk of potentially life-threatening cardiac complications. Options 2, 3 and 4 represent levels within the typical range.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client with heart failure is experiencing shortness of breath and peripheral edema. Their physician orders furosemide (Lasix) 40 mg intravenously daily. Which assessment finding would MOST closely indicate the medication is achieving its therapeutic effect?
सही उत्तर: घ) Reduced pitting edema.
Option 3 is correct. Furosemide is a loop diuretic that reduces fluid volume, leading to decreased pulmonary congestion and edema. Crackles in the lungs are a direct result of this reduced fluid buildup. Option 1 describes a potentially adverse effect (reduced urine output), option 2 contradicts the drug’s action, and option 4 isn't a primary indicator of diuretic effectiveness.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client with a diagnosis of chronic obstructive pulmonary disease (COPD) presents to the emergency department with shortness of breath and an oxygen saturation of 85% on room air. Which intervention is MOST important for the nurse to perform immediately? (A) Administering bronchodilators via nebulizer. (B) Positioning the client in a high-fowler’s position. (C) Assessing the client's respiratory rate and pattern. (D) Obtaining a sputum sample for culture.
सही उत्तर: ख) Positioning the client in a high-fowler’s position.
The best response is (1) because improving oxygenation is the immediate priority when a patient with COPD has hypoxemia. Option (B) is supportive but doesn't address the underlying cause of hypoxia. Assessing respiratory rate and pattern (C) is important, but secondary to initiating treatment. Obtaining a sputum sample (D) takes time and does not improve oxygen saturation immediately.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client following a total hip arthroplasty (THA) has developed pain rated as 8/10. The nurse assesses the surgical site and notes redness, warmth, and swelling. Which intervention should the nurse implement FIRST? (A) Administering an analgesic medication as prescribed. (B) Applying ice packs to the surgical dressing for 20 minutes at a time. (C) Elevating the affected leg above the level of the heart. (D) Encouraging the client to perform range-of-motion exercises.
सही उत्तर: ख) Applying ice packs to the surgical dressing for 20 minutes at a time.
The correct answer is (1) because pain management is paramount. While other interventions are important, addressing the pain first is crucial. Option (B), (C) and (D) delay pain relief. It’s critical to manage pain effectively before starting physical therapy or mobilization.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client is admitted with severe dehydration following vomiting. Vital signs include temperature 38°C (100.4°F), heart rate 120 bpm, blood pressure 90/60 mmHg, and mucous membranes are dry. Which of the following nursing interventions is MOST appropriate at this time? (A) Administering intravenous fluids rapidly to restore fluid volume. (B) Monitoring urine output closely and encouraging oral intake of clear liquids. (C) Assessing for signs of cerebral edema, such as altered mental status. (D) Applying a cool compress to the client’s forehead.
सही उत्तर: ख) Monitoring urine output closely and encouraging oral intake of clear liquids.
The correct answer is (1) because rapid fluid administration could worsen cerebral edema in this dehydrated state. Option (A) is incorrect because rapid infusion can be dangerous. Option (B) is partially correct but less immediate than carefully monitoring for complications. Option (C) is a potential concern and needs assessment, however monitoring urine output is the priority action. Option (D) is not indicated as it doesn’t address the underlying cause.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A patient with psychosis exhibits disorganized speech patterns – frequently jumping between topics and using illogical connections. Which nursing intervention would be MOST appropriate?
सही उत्तर: घ) Provide a quiet, structured environment with minimal distractions
Maintaining a structured environment and avoiding direct questioning is key when dealing with disorganized speech. While routines can be helpful, forcing coherence will likely exacerbate the symptoms. This aligns with NCLEX’s emphasis on minimizing distress and promoting patient comfort.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client with a history of major depressive disorder expresses hopelessness about their future. During the conversation, they state, 'What's the point? Nothing ever gets better.' Which response from the nurse would be MOST therapeutic?
सही उत्तर: ग) ‘Tell me more about what makes you feel this way and let's explore some possible solutions.’
The most therapeutic response demonstrates empathy and encourages further exploration of the client’s thoughts and emotions, moving towards problem-solving. Simply stating there's 'something to look forward to' is dismissive. Offering solutions prematurely or focusing solely on positivity isn’t effective for someone in a deep state of hopelessness.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A patient recently diagnosed with bipolar disorder is experiencing manic symptoms including grandiose ideas, racing thoughts, and impulsive spending. Which of the following interventions would be MOST crucial to implement immediately?
सही उत्तर: ख) Implement a structured routine and limit exposure to stimulating environments
Limiting stimulation is critical in managing acute mania as it directly addresses the key symptoms. The other options exacerbate the situation – encouraging disorganized thoughts, facilitating impulsive behavior, or providing additional stimuli can prolong the manic episode. This aligns with NCLEX’s emphasis on immediate safety and symptom management.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
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A client admitted for acute anxiety states expresses significant distress about perceived threats to their safety. Which of the following therapeutic approaches would be MOST appropriate in this scenario?
सही उत्तर: ग) Employ relaxation techniques such as deep breathing or progressive muscle relaxation to manage physiological symptoms
Relaxation techniques are evidence-based interventions for acute anxiety. Directly challenging paranoid delusions can be counterproductive and worsen distress. While other options have a place in long-term management, relaxation offers immediate symptom relief aligned with NCLEX priorities.
💬 टिप्पणी / गल्ती रिपोर्ट (०)
यी अभ्यास प्रश्न हुन्, आधिकारिक प्रश्न होइनन्। पाठ्यक्रम, विज्ञापन र नतिजाका लागि सम्बन्धित निकायको आधिकारिक वेबसाइट हेर्नुहोस्। उत्तरमा गल्ती भेटे प्रश्नमुनिको "टिप्पणी / गल्ती रिपोर्ट" मा लेख्नुहोस्।
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