NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer. Teaching related to skin care for the client would include which of the following?
Correct Answer: D
Rationale: The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
Question 2 of 5
Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with:
Correct Answer: B
Rationale: Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. The client has symptoms of dystonia but not of parkinsonism. The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.
Question 3 of 5
The nurse is teaching a client with a history of sleep apnea about self-care. The nurse should tell the client to:
Correct Answer: A
Rationale: A CPAP machine maintains airway patency in sleep apnea, improving oxygenation and reducing apneic episodes.
Question 4 of 5
A 30-year-old client is exhibiting auditory hallucinations. In working with this client, the nurse would be most effective if the nurse:
Correct Answer: B
Rationale: This answer is incorrect. Encouraging discussion of the voices will reinforce the delusion. This answer is correct. The nurse should appropriately present reality. This answer is incorrect. Showing interest would reinforce the delusional system. This answer is incorrect. The statement only indicates that the client is hearing voices. It does not state that the client is acting out.
Question 5 of 5
A female client has been recently diagnosed as bipolar. She has taken lithium for the past several weeks to control mania. What must be included in client education regarding lithium toxicity?
Correct Answer: C
Rationale: The client should maintain a normal diet including normal salt intake. A low-sodium diet can cause lithium retention, leading to toxicity. Lithium must be taken with meals because it is irritating to the gastric mucosa. Diarrhea, vomiting, or diaphoresis can cause dehydration, which will increase lithium blood levels. If these symptoms occur, the nurse should instruct the client to withhold lithium. Lithium is not to be taken with over-the-counter drugs without specific instruction. Some drugs raise lithium levels, whereas others lower lithium levels.