NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A type I diabetic client delivers a male newborn. The newborn is 45 minutes old. What is the primary nursing goal in the nursery during the first hours for this newborn?
Correct Answer: B
Rationale: The infant will be at risk for hypoglycemia because of excess insulin production.
Question 2 of 5
A dose of theophylline may need to be altered if a client with COPD:
Correct Answer: D
Rationale: The effects of morphine or an allergic response to the drug will not affect theophylline clearance. Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
Question 3 of 5
A common complaint of the client with an abdominal aortic aneurysm is:
Correct Answer: D
Rationale: A pulsating sensation in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding vessel. The other symptoms are less specific or unrelated.
Question 4 of 5
A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self-mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by:
Correct Answer: C
Rationale: Threatening a client with punitive action is violating a client's rights and could escalate the client's anger. Angry clients need respect for personal space, and physical contact may be perceived as a threatening gesture escalating anger. Client lacks sufficient self-control to limit own maladaptive behavior; she may need assistance from staff. Confronting an angry client may escalate her anger to further acting out, and consequences are for acting out anger aggressively, not for getting angry or feeling angry.
Question 5 of 5
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:
Correct Answer: A
Rationale: This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B,
C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. This answer is incorrect.
Toxic poisoning is usually at the 2.0 level or higher.