NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:
Correct Answer: C
Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.
Question 2 of 5
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
Correct Answer: A
Rationale: This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B,
C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. This answer is incorrect.
Toxic poisoning is usually at the 2.0 level or higher.
Question 3 of 5
A common complaint of the client with an abdominal aortic aneurysm is:
Correct Answer: D
Rationale: A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.
Question 4 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 5 of 5
A client with a history of epilepsy is admitted with complaints of aura. The nurse should give priority to:
Correct Answer: A
Rationale: An aura signals an impending seizure, so ensuring safety (e.g., padding, side-lying position) is the priority.