NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
Question 2 of 5
The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
Question 3 of 5
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:
Correct Answer: C
Rationale: Autonomic dysreflexia is an exaggerated reflex of the autonomic nervous system causing vasoconstriction and elevated blood pressure, often presenting with headache and facial flushing. The other symptoms listed are not associated with this condition.
Question 4 of 5
A 10-year-old boy has been diagnosed with Legg-Calvé Perthes disease. Which of the client's responses would indicate compliance during initial therapy?
Correct Answer: B
Rationale: This condition causes aseptic necrosis of the head of the femur in the acetabulum. Drinking large quantities of milk at this time cannot hasten recovery. The aim of treatment is to keep the head of the femur in the acetabulum. Nonweight-bearing is essential. Activity causes microfractures of the epiphysis. In addition to nonweight-bearing, clients are often placed on bedrest, which helps to reduce inflammation. Later, active motion is encouraged. Weight is not generally an issue with this disease. Slipped femoral capital epiphysis, which is most frequently observed in obese pubescent children, usually requires a weight reduction diet.
Question 5 of 5
The client is diagnosed with a pneumothorax. Which finding is most expected on auscultation?
Correct Answer: B
Rationale: A pneumothorax causes collapsed lung tissue, resulting in diminished or absent breath sounds on the affected side. Crackles, wheezing, and rhonchi are not typical.