NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
Question 2 of 5
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
Question 3 of 5
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
Question 4 of 5
A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client for:
Correct Answer: C
Rationale: Hoarseness is a common symptom of metastatic lung cancer due to tumor effects on the larynx or recurrent laryngeal nerve. Constipation, diarrhea, and weight gain are less specific.
Question 5 of 5
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action should the nurse plan to take while the client is taking this medication?
Correct Answer: D
Rationale: Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. The medication may cause hypoglycemia, not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes.