NCLEX-RN
Practice NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?
Correct Answer: B
Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.
Question 2 of 5
A client is receiving an opioid per patient-controlled analgesia (PCA) pump to control postoperative pain; however, when the nurse assesses the client, she finds the client is pale and hypotensive, and has a respiratory rate of 6 breaths per minute. The PCA pump record shows that the limit for maximum dosage was set far too high, resulting in an overdose. The client is very somnolent and barely responsive. What interventions does the nurse anticipate? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Opioid overdose requires stopping the infusion (
A), administering naloxone (
C) to reverse effects, providing oxygen (
D) for respiratory depression, and filing an incident report (E). Discontinuing the PCA (
B) is not immediate.
Question 3 of 5
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
Question 4 of 5
Damage to the VII cranial nerve results in:
Correct Answer: C
Rationale: The VII cranial nerve (facial nerve) controls facial muscles; damage causes facial paralysis, affecting eye movement (e.g., inability to close the eye).
Question 5 of 5
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.