NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following?
Correct Answer: D
Rationale: Lorazepam, a benzodiazepine, can cause anticholinergic side effects such as dry mouth, constipation, or confusion, especially in elderly clients with Alzheimer's. Extrapyramidal effects are associated with antipsychotics, and vomiting is less common.
Question 2 of 5
A client with a history of type 2 diabetes is prescribed sitagliptin (Januvia). The nurse should instruct the client to:
Correct Answer: B
Rationale: Sitagliptin can cause pancreatitis, requiring monitoring for abdominal pain.
Question 3 of 5
Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to maintain the patient's confidentiality. The client's family cannot request release of medical information without the client's consent. A physician's order is not a substitute for a client's consent to release medical information in the absence of a communicable disease.
Correct Answer: A
Rationale: Reporting STDs to public health agencies is mandatory, but confidentiality must be maintained except in specific legal circumstances.
Question 4 of 5
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
Question 5 of 5
When quinidine gluconate is prescribed for a client the nurse reviews the client's medical record. Which condition is a contraindication in the use of this medication?
Correct Answer: D
Rationale: Quinidine gluconate is an antidysrhythmic medication used as prophylactic therapy to maintain normal sinus rhythm after conversion of atrial fibrillation and/or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, abnormal impulses and rhythms caused by escape mechanisms, and myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency.