NCLEX-RN
Practice NCLEX RN Test Questions
Extract:
Question 1 of 5
A client with schizophrenia has been taking Clozaril (clozapine) for the past 6 months. This morning the client's temperature was elevated to 102°F. The nurse should give priority to:
Correct Answer: C
Rationale: A fever of 102°F in a client on clozapine may indicate agranulocytosis, a life-threatening side effect, requiring immediate physician notification.
Question 2 of 5
The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
Correct Answer: C
Rationale: Fried fish is high in fat and residue, which can exacerbate symptoms in Crohn's disease; low-residue diets emphasize easily digestible foods.
Question 3 of 5
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:
Correct Answer: A
Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.
Question 4 of 5
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.
Question 5 of 5
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified