NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
Question 2 of 5
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
Correct Answer: B
Rationale: Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. This statement is true. These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.
Question 3 of 5
The client is admitted with a possible myocardial infarction. The nurse would anticipate an order from the physician for which laboratory test?
Correct Answer: A, C, D
Rationale: Creatine kinase (
A), myoglobin (
C), and troponin T (
D) are cardiac biomarkers elevated in myocardial infarction. Ammonia (
B), gamma-glutamyl transferase (E), and bilirubin (F) are unrelated to acute cardiac events.
Question 4 of 5
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
Question 5 of 5
The nurse assesses a client's monitor strip and finds the following: uterine contractions every 3-4 minutes, lasting 60-70 seconds; FHR baseline 134-146 bpm, with accelerations to 158 bpm with fetal movement. Which nursing intervention is appropriate?
Correct Answer: D
Rationale: These indices are within normal parameters; therefore, the nurse does not need to contact the physician. The purpose of turning a client to her left side is to maximize uteroplacental blood flow. Based on the above assessment, there is no indication that blood flow is compromised. These interventions are appropriate nursing interventions for late and prolonged decelerations. Following these interventions, the nurse should notify the physician. These indices are within normal parameters; therefore, the nurse does not need to start an IV and administer O2. Variations of 20 bpm above or below the baseline FHR is considered normal. Normal FHRs range from 120-160 bpm. As the fetus moves, the FHR increases, and accelerations often occur in concert with contractions. During the active phase of labor, the frequency of uterine contractions is every 2-4 minutes, with an appropriate duration of 60 sec.