NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:
Correct Answer: B
Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.
Question 2 of 5
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
Correct Answer: D
Rationale: Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis. Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
Question 3 of 5
Which action by the home health nurse indicates a knowledge of the needs of an elderly client?
Correct Answer: D
Rationale: Fall prevention is a critical need for elderly clients due to risks of injury from reduced mobility or balance. Hospice teaching is premature, high-pitched speech may not aid hearing, and fluid restriction can cause dehydration.
Question 4 of 5
A client with cancer who is receiving chemotherapeutic drugs has been given injections of pegfilgastrim (Neulasta). Which laboratory value reveals that the drug is producing the desired effect?
Correct Answer: B
Rationale: Pegfilgastrim stimulates neutrophil production, increasing white blood cell counts. A WBC of 6,000/mm (
B) indicates effectiveness. Hemoglobin (
A), platelets (
C), and hematocrit (
D) are not directly affected.
Question 5 of 5
The nurse is caring for a client with a history of rheumatoid arthritis who is receiving Methotrexate (Rheumatrex). The nurse should monitor the client for:
Correct Answer: A
Rationale: Methotrexate can cause hepatotoxicity, requiring monitoring of liver enzymes. Hypotension, hyperglycemia, and thrombocytosis are not common side effects.