Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?

Correct Answer: B

Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.

Question 2 of 5

Which of the following should the nurse do first for a toddler just admitted with croup?

Correct Answer: B

Rationale: Assessing respiratory status is the priority for a toddler with croup, as airway obstruction is a primary concern. Vital signs, fluids, and tracheostomy preparation are secondary.

Question 3 of 5

The nurse identifies the type of presentation shown in the fi gure as which of the following?

Question Image

Correct Answer: C

Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.

Question 4 of 5

You are caring for an acute care adult client in the medical unit who has no history of a psychiatric mental health disorder. This 76 year old client has suddenly and abruptly started to exhibit episodic and intermittent periods of time vacillating between periods of impaired cognition and periods of mental clarity. The client reports to you that they are seeing clowns in their room. This client is dehydrated and has just begun taking an anticholinergic medication. Which of the following is the most appropriate nursing diagnosis for this client?

Correct Answer: D

Rationale: The sudden onset of impaired cognition, fluctuating mental status, and visual hallucinations in the context of dehydration and anticholinergic medication use strongly suggests delirium, not dementia or psychosis.

Question 5 of 5

The nurse is assessing a client with suspected pulmonary edema. Which finding supports this diagnosis?

Correct Answer: A

Rationale: Crackles in the lung bases indicate fluid accumulation in the alveoli, a key sign of pulmonary edema requiring urgent intervention.

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