NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Using an electric razor prevents the risk of cuts while shaving. Any physician or dentist should be informed of anticoagulant therapy because of the risk of bleeding due to a prolonged PT. The client should be instructed to consult with his physician. Aspirin is avoided because it potentiates the effects of oral anticoagulants by interfering with platelet aggregation. Identification bracelets are necessary to direct treatment, especially in an emergency situation.
Question 2 of 5
A client with Crohn's disease requires TPN to provide adequate nutrition. The nurse finds the TPN bag empty. What fluid would the nurse select to hang until another bag is prepared in the pharmacy?
Correct Answer: C
Rationale: D10W provides glucose to prevent hypoglycemia when TPN is interrupted, as TPN contains high dextrose. Lactated Ringers (
A), normal saline (
B), and Normosol R (
D) lack sufficient glucose.
Question 3 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 4 of 5
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:
Correct Answer: B
Rationale: Drinking water or gargling after using a steroid inhaler like beclomethasone prevents oral candidal infections, a common side effect.
Question 5 of 5
The nurse is caring for a child with a diagnosis of possible hydrocephalus. Which assessment data on the admission history would be the most objective?
Correct Answer: C
Rationale: Head measurement (e.g., head circumference) is the most objective for hydrocephalus, directly assessing skull enlargement. Anorexia (
A), vomiting (
B), and temperature (
D) are subjective or less specific.