NCLEX-RN
NCLEX RN Practice Questions Free Questions
Extract:
Question 1 of 5
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
Correct Answer: C
Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
Question 2 of 5
A client with a history of chronic kidney disease is admitted with complaints of fatigue. The nurse should give priority to:
Correct Answer: A
Rationale: Fatigue in chronic kidney disease often results from anemia due to low erythropoietin, so monitoring for anemia is the priority.
Question 3 of 5
The nurse is teaching a client with a history of hypertension about medication adherence. The nurse should tell the client to:
Correct Answer: A
Rationale: Adherence to antihypertensives is critical in hypertension to maintain blood pressure control and prevent complications.
Question 4 of 5
The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?
Correct Answer: A
Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.
Question 5 of 5
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
Correct Answer: C
Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.