NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
A client with AIDS is admitted with a diagnosis of pneumocystis carinii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is:
Correct Answer: B
Rationale: The client's confusion and disorientation pose a risk for injury, such as pulling out the IV or falling, making this the priority nursing diagnosis.
Question 2 of 5
The physician has ordered sublingual nitroglycerin for a client. Which of the following are contraindications for administration of sublingual or buccal medications? Select all that apply.
Correct Answer: C,D
Rationale: Red, irritated mucous membranes (
C) and dehydration (
D) impair sublingual absorption. Edentulous state (
A), mild dementia (
B), and aphasia (E) do not contraindicate sublingual administration.
Question 3 of 5
The nurse has received report on the day's assigned clients. Which of the following clients should the nurse see first?
Correct Answer: D
Rationale: Tingling around the mouth after an antibiotic suggests an allergic reaction, potentially anaphylaxis, requiring immediate assessment.
Question 4 of 5
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
Question 5 of 5
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
Correct Answer: A
Rationale: Echinacea may interact with antiretroviral medications, potentially reducing their effectiveness.