NCLEX-RN
NCLEX RN Practice Questions with Answers Questions
Extract:
Question 1 of 5
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should:
Correct Answer: A
Rationale: Increasing oxygen flow within the ordered range addresses increasing dyspnea and maintains oxygenation, which is the priority in suspected pulmonary embolism.
Question 2 of 5
A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
Question 3 of 5
The home care nurse notes that an older client is prescribed cimetidine. On assessment of the client, the nurse should check for which side effect of this medication?
Correct Answer: B
Rationale: Cimetidine is a gastric acid secretion inhibitor. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, agitation, and hallucinations. None of the remaining options are associated with the use of this medication.
Question 4 of 5
The nurse cares for a client receiving fludrocortisone acetate for the treatment of Addison's disease. When monitoring the client for improvement, what anticipated therapeutic effect of this medication will the nurse focus on?
Correct Answer: A
Rationale: Fludrocortisone acetate is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that may be used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. The client can rapidly develop hypotension and fluid and electrolyte imbalance if the medication is discontinued abruptly. The medication does not affect the immune response or thyroid or thyrotropin production.
Question 5 of 5
The nurse is preparing to insert a urinary catheter. Which action ensures sterile technique?
Correct Answer: C
Rationale: Applying sterile lubricant to the catheter tip maintains sterile technique, reducing the risk of infection during urinary catheter insertion.