NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?
Correct Answer: B
Rationale: Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question 2 of 5
A client with a history of a brain tumor is scheduled for a craniotomy. The nurse should:
Correct Answer: B
Rationale: Antibiotics are often given preoperatively for a craniotomy to prevent infection. Shaving is per protocol, flat positioning may increase ICP, and exercises are taught post-op.
Question 3 of 5
A client with a history of hyperparathyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
Correct Answer: A
Rationale: Hyperparathyroidism increases parathyroid hormone, leading to hypercalcemia, causing fatigue and other symptoms.
Question 4 of 5
A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:
Correct Answer: D
Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.
Question 5 of 5
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
Correct Answer: B
Rationale: The infant will be at risk for hypoglycemia because of excess insulin production.