NCLEX-RN
NCLEX RN Question Bank Free Questions
Extract:
Question 1 of 5
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.
Question 2 of 5
An intravenous dose of lorazepam is prescribed for a client. Which data from the client's history would indicate the need to consult with the primary health care provider before administering the medication?
Correct Answer: A
Rationale: Lorazepam is a benzodiazepine and is contraindicated in clients who are comatose, with preexisting central nervous system (CNS) depression, with uncontrolled severe pain, and those with narrow-angle glaucoma. It is also contraindicated if hypersensitivity or cross-sensitivity with other benzodiazepines exists. It is also not prescribed for clients who are pregnant or breast-feeding.
Question 3 of 5
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.
Question 4 of 5
A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.
Question 5 of 5
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.