NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
Question 2 of 5
A patient with a PCA pump (patient controlled analgesia) asks the nurse if he can become overdosed with pain medication using this machine. Which statement made by the nurse is correct?
Correct Answer: B
Rationale: PCA pumps have a lockout interval and dose limits programmed to prevent overdose, ensuring safe administration of pain medication. The other statements are inaccurate: PCA requires patient action, does not deliver large doses every four hours, and is not based on ‘need’ detection.
Question 3 of 5
The nurse needs to be aware that the most common early complication of a myocardial infarction is:
Correct Answer: D
Rationale: Myocardial infarction causes tissue damage, which may interrupt electrical impulses. Myocardial irritability results from lack of oxygenated tissue.
Question 4 of 5
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
Correct Answer: C
Rationale: The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately.
Question 5 of 5
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.