NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
Question 2 of 5
The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
Correct Answer: C
Rationale: Subjective information is provided by a person.
Question 3 of 5
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
Correct Answer: A
Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C,
D) The other responses are not expected in this situation and are not even side effects.
Question 4 of 5
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
Question 5 of 5
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
Correct Answer: B
Rationale: (A,
D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.