NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client has ascites, which is caused by:
Correct Answer: A
Rationale: A decrease in plasma proteins causes a decrease in intravascular osmotic pressure resulting in leakage of fluid into peritoneal cavity.
Question 2 of 5
A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?
Correct Answer: B
Rationale: Indigestion or nausea may accompany angina or myocardial infarction, but they do not indicate imminent danger for the client. Restlessness and apprehensiveness require immediate nursing action because they are indicative of very low oxygenation of body tissues and are frequently the first indication of impending cardiac or respiratory arrest. It is common for the cardiac client to experience fatigue and inability to physically tolerate long assessment sessions. A history of hypertension requires no immediate nursing intervention. In the situation described, the blood pressure is not given and therefore cannot be assumed to be elevated.
Question 3 of 5
When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:
Correct Answer: C
Rationale: Pericarditis can cause dyspnea but primarily causes chest pain. Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.
Question 4 of 5
The physician has prescribed imipramine (Tofranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for:
Correct Answer: C
Rationale: Tricyclic antidepressants like imipramine take 2-4 weeks for maximal therapeutic effects due to gradual neurotransmitter changes. Monitoring affect is essential during this period.
Question 5 of 5
A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet?
Correct Answer: C
Rationale: Cantaloupe is a good source of carbohydrates, vitamin C, and vitamin A. Rice contains about 4 g of protein per 200 g. Chicken contains 35 g protein per breast. Chicken is a rich source of vitamin B6 (pyridoxine), which is needed for adequate protein synthesis. As protein intake increases, vitamin B6 intake must also be increased. Vitamin B6 is a coenzyme in amino acid metabolism. Green beans only contain 2 g of protein per cup.