NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 2 of 5
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving Methotrexate (Rheumatrex). The nurse should monitor the client for:
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and thrombocytosis are not common side effects.
Question 3 of 5
When assessing the client with acute arterial occlusion, the nurse would expect to find:
Correct Answer: B
Rationale: Acute arterial occlusion causes ischemia, leading to tissue necrosis, which may present as minute blackened areas on the toes, indicating severe ischemia.
Question 4 of 5
The nurse is caring for a client with a colostomy. Which finding requires immediate intervention?
Correct Answer: D
Rationale: A significantly protruding stoma may indicate prolapse, a complication requiring immediate intervention to prevent ischemia or obstruction. Pink stoma, cramping, and liquid stool are normal or less urgent.
Question 5 of 5
The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: A respiratory rate of 10 breaths per minute suggests magnesium toxicity as magnesium sulfate depresses the central nervous system including respiratory drive. Normal reflexes adequate urine output and BP of 140/90 do not indicate toxicity.