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Questions 158

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NCLEX RN Nursing Exam Questions

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Question 1 of 5

A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?

Correct Answer: A

Rationale: This answer is correct. A balanced diet with adequate salt intake is necessary. This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000-3000 mL/day). This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.

Question 2 of 5

Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?

Correct Answer: A

Rationale: Increased ICP is indicated by Cushing’s triad: hypertension (BP 180/70), bradycardia (pulse 50), and irregular respirations. Option A best matches this, with fever as a possible secondary sign. Options B, C, and D lack this combination.

Question 3 of 5

When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance of feeding her child:

Correct Answer: C

Rationale: Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. Diluted soft drinks have a high-carbohydrate content, which aggravates the diarrhea. Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. Regular formulas contain lactose, which can increase diarrhea.

Question 4 of 5

The nurse is caring for a client with a history of a mastectomy who is receiving radiation therapy. The nurse should teach the client to:

Correct Answer: C

Rationale: Avoiding sun exposure to the radiated area prevents further skin damage and irritation. Lotion, air exposure, and heating pads can worsen skin integrity.

Question 5 of 5

The registered nurse is making assignments for the day. Which client should be assigned to the nurse who is pregnant?

Correct Answer: D

Rationale: Valganciclovir for cytomegalovirus poses minimal risk to a pregnant nurse as it is not teratogenic and standard precautions suffice. Pentamidine ribavirin and radium implants carry higher risks due to potential teratogenicity or radiation exposure.

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