NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
Correct Answer: D
Rationale: Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
Question 2 of 5
The nurse is caring for a client with a tracheostomy. Which action is a priority to prevent complications?
Correct Answer: A
Rationale: Suctioning as needed prevents airway obstruction from mucus buildup, a priority to maintain patency and prevent respiratory distress. Cuff management, tie changes, and infection monitoring are important but secondary to airway maintenance.
Question 3 of 5
A client with a history of chronic kidney disease is admitted with complaints of shortness of breath. The nurse should give priority to:
Correct Answer: A
Rationale: Shortness of breath in chronic kidney disease may indicate fluid overload, so administering diuretics is the priority.
Question 4 of 5
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:
Correct Answer: A
Rationale: Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
Question 5 of 5
A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?
Correct Answer: B
Rationale: Pegfilgastrim stimulates neutrophil production, increasing white blood cell counts. A WBC of 6,000/mm (
B) indicates effectiveness. Hemoglobin (
A), platelets (
C), and hematocrit (
D) are not directly affected.