NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A laboratory technique specific for diagnosing Lyme disease is:
Correct Answer: A
Rationale: Polymerase chain reaction is the laboratory technique specific for Lyme disease. Heterophil antibody test is used to diagnose mononucleosis. Lyme disease does not decrease the serum calcium level. Lyme disease does not increase the serum potassium level.
Question 2 of 5
A client is admitted with a blood glucose level of 740 mg/dl. Which actions should the nurse take at this time?
Correct Answer: C, E, F
Rationale: Hyperglycemia (740 mg/dl) requires physician notification (
C), sliding scale regular insulin (E), and consciousness assessment (F) for potential diabetic ketoacidosis. Peripheral neuropathy (
A) is chronic, not acute. Dextrose (
B) worsens hyperglycemia. NPH insulin (
D) is long-acting, unsuitable for acute management.
Question 3 of 5
The client is receiving a continuous infusion of propofol (Diprivan) for sedation. Which assessment is most important?
Correct Answer: A
Rationale: Propofol can cause respiratory depression, so monitoring respiratory rate is critical to detect apnea or hypoventilation. Blood pressure, pulse, and temperature are monitored but are less immediate concerns.
Question 4 of 5
A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:
Correct Answer: B
Rationale: This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help.
Question 5 of 5
A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, 'I can't stay still at night. I toss and turn and can't fall asleep.' The nurse suspects that she may be experiencing:
Correct Answer: A
Rationale: Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.