NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should:
Correct Answer: D
Rationale: Massage over a reddened area on a bony prominence is contraindicated as it can further damage tissue and reduce blood flow, increasing the risk of pressure ulcers. The nurse should instruct the assistant to stop massaging the area to prevent harm.
Question 2 of 5
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
Question 3 of 5
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
Question 4 of 5
Before the nurse administers I.V. replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?
Correct Answer: B
Rationale: Evaluating electrolyte levels, especially potassium, is critical before administering potassium chloride to prevent hyperkalemia. Adding potassium at the bedside is unsafe, and priming or checking rates follows.
Question 5 of 5
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.