NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?
Correct Answer: B
Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (
A), hypotension (
C), and hair loss (
D) are not typical.
Question 2 of 5
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
Question 3 of 5
The client has surgery for removal of a prolactinoma. Which of the following interventions would be appropriate for this client?
Correct Answer: C
Rationale: After prolactinoma surgery (transsphenoidal hypophysectomy) elevating the head of the bed 30° reduces intracranial pressure and prevents cerebrospinal fluid leakage. Trendelenburg position coughing and nose blowing may increase pressure or disrupt the surgical site.
Question 4 of 5
A client with a history of multiple myeloma is admitted with complaints of bone pain. The nurse should give priority to:
Correct Answer: B
Rationale: Bone pain in multiple myeloma is often due to bone destruction, which can cause hypercalcemia, so monitoring for hypercalcemia is the priority.
Question 5 of 5
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.