NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority?
Correct Answer: A
Rationale: An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
Question 2 of 5
The client is prescribed metronidazole (Flagyl) for a parasitic infection. Which side effect should the nurse monitor for?
Correct Answer: A
Rationale: Metronidazole commonly causes a metallic taste in the mouth. Hypotension, weight gain, and fever are not typical side effects.
Question 3 of 5
The nurse is assessing the laboratory results of a client scheduled to receive phenytoin sodium (Dilantin). The Dilantin level, drawn two hours ago, is 30 mcg/mL. What is the appropriate nursing action?
Correct Answer: B
Rationale: A Dilantin level of 30 mcg/mL is toxic (therapeutic range: 10–20 mcg/mL). Holding the dose and notifying the physician prevents toxicity. Administering (
A), decreasing (
C), or increasing (
D) the dose without physician input is unsafe.
Question 4 of 5
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, 'Nurse, the baby is coming.' As the nurse responds to her call, which one of the following observations should the nurse make first?
Correct Answer: A
Rationale: The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
Question 5 of 5
A 7-year-old girl has been diagnosed with juvenile arthritis and has been placed on daily aspirin. Which statement made by the parent indicates a need for further teaching?
Correct Answer: B
Rationale: Aspirin should not be given on an empty stomach because it is irritating to the mucosa. Bleeding from decreased clotting capacity may be caused by aspirin toxicity. A regular schedule of aspirin administration is important to maintain a satisfactory drug level in the body. Aspirin toxicity may affect cranial nerve VIII, leading to tinnitus (ringing in the ears).