NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
A client with a history of a burn injury is receiving Silvadene (silver sulfadiazine). The nurse should monitor the client for:
Correct Answer: A
Rationale: Silver sulfadiazine can cause neutropenia, requiring monitoring of white blood cell counts. Hyperkalemia, hypoglycemia, and hypertension are not typical side effects.
Question 2 of 5
The nurse is caring for a client with a history of a hip fracture who is in Buck’s traction. The nurse should:
Correct Answer: C
Rationale: In Buck’s traction, weights must hang freely off the floor to maintain proper traction force. Turning is limited, traction is not removed, and lotion is unnecessary.
Question 3 of 5
A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include:
Correct Answer: C
Rationale: The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. Depressed persons often have little appetite and poor fluid intake. Constipation is common. A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.
Question 4 of 5
A client with a history of a kidney transplant is receiving Prednisone. The nurse should monitor the client for:
Correct Answer: A
Rationale: Prednisone, a corticosteroid, suppresses immunity, increasing infection risk. Hypotension, hyperkalemia, and weight loss are not primary concerns; weight gain is more common.
Question 5 of 5
During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:
Correct Answer: A
Rationale: The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. Echopraxia is mimicking the movements of another person. Echolalia is mimicking the speech of another person.