NCLEX-RN
NCLEX RN Free Practice Questions Questions
Extract:
Question 1 of 5
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
Correct Answer: B
Rationale: Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should be notified immediately so that a serum theophylline level can be ordered.
Question 2 of 5
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
Correct Answer: B
Rationale: Anemia and vomiting are not cardinal signs of diabetes insipidus. Polyuria and polydipsia are the cardinal signs of diabetes insipidus. Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
Question 3 of 5
Home-care instructions for the child following a cardiac catheterization should include:
Correct Answer: B
Rationale: A small bruise may develop around the insertion site and is not a reason for alarm. It is best to keep the child out of the bathtub until the sutures are removed. Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. The insertion site should be kept clean and dry and open to air.
Question 4 of 5
A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.
Question 5 of 5
A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding:
Correct Answer: C
Rationale: The client may be anxious and hyperresponsive to stimuli but not necessarily restless. This is not a physiological response to an elevated blood pressure in PIH. The nurse must know the nursing measures that decrease the potential for convulsions. A quiet, darkened room decreases stimuli and promotes rest. External stimuli might induce a convulsion but are not annoying to the client with PIH.