NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
Correct Answer: D
Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
Question 2 of 5
A client with a history of Addison's disease is admitted with complaints of nausea and vomiting. The nurse should expect the client to have:
Correct Answer: A
Rationale: Addison's disease causes adrenal insufficiency, reducing aldosterone, which leads to hyperkalemia due to impaired potassium excretion.
Question 3 of 5
The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:
Correct Answer: A
Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.
Question 4 of 5
The nurse is assessing a client with suspected dehydration. Which finding is most indicative?
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.
Question 5 of 5
A client with a history of glaucoma is prescribed timolol (Timoptic) eye drops. Which instruction should the nurse include in the teaching?
Correct Answer: B
Rationale: Pressing the inner corner (nasolacrimal occlusion) after instilling timolol prevents systemic absorption. Direct corneal application (
A) is incorrect, pain-based use (
C) is wrong, and refrigeration (
D) is unnecessary.