NCLEX-RN
RN NCLEX Practice Test Questions
Extract:
Question 1 of 5
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to 'having a few drinks now and then.' He is probably experiencing which of the following?
Correct Answer: B
Rationale: Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.
Question 2 of 5
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
Correct Answer: C
Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.
Question 3 of 5
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.
Question 4 of 5
A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem?
Correct Answer: D
Rationale: Acetaminophen (Tylenol) has analgesic and antipyretic actions approximately equivalent to those of aspirin. It produces analgesia possibly by action on the peripheral nervous system. It reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vasodilation. It is generally used for temporary relief of mild to moderate pain, such as a simple headache, minor joint and muscle pains, and control of fever. Meperidine is a narcotic agonist analgesic with properties similar to morphine except that it has a shorter duration of action and produces less depression of urinary retention and smooth muscle spasm. It is used for moderate to severe pain, for a preoperative medication, for support of anesthesia, and for obstetrical analgesia. In a postoperative TURP client, it would be used in conjunction with other medications for relief of moderate to severe pain, but not specifically for bladder spasms associated with TURP surgery. Promethazine hydrochloride is an antihistamine, antiemetic preparation. It exerts antiserotonin, anticholinergic, and local anesthetic actions. It is used for symptomatic relief of various allergic conditions, motion sickness, nausea, and vomiting. It is used for preoperative, postoperative, and obstetrical sedation and as an adjunct to analgesics for control of pain. This answer is correct because aminocaproic acid is prescribed specifically for hematuria. Aminocaproic acid is excreted in the urine. The nurse should be alert for possible signs of thrombosis, particularly in the extremities.
Question 5 of 5
The nurse is caring for a client with a history of a tracheoesophageal fistula. The nurse should:
Correct Answer: D
Rationale: A tracheoesophageal fistula risks aspiration, requiring restricted oral intake until surgically repaired. Positioning, suctioning, and feedings are secondary or contraindicated.