NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 2 of 5
A post-operative client has an order for Demerol (meperidine) 75 mg and Phenergan (promethazine) 25 mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an:
Correct Answer: B
Rationale: Meperidine (opioid) and promethazine (antihistamine) together produce a synergistic effect, enhancing pain relief and sedation. Promethazine potentiates meperidine’s effects.
Question 3 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 4 of 5
The nurse is caring for a patient following a thyroidectomy. Which of the following is an early symptom of hypocalcemia?
Correct Answer: C
Rationale: Numbness or tingling in the extremities is an early sign of hypocalcemia, which can occur post-thyroidectomy due to parathyroid gland disruption. Chvostek’s sign and prolonged QT intervals are later signs, and 3+ reflexes are not specific.
Question 5 of 5
The nurse has just received the change of shift report. Which client should the nurse assess first?
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment.