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 client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
Correct Answer: C
Rationale: Neomycin is an antibiotic, but this is not the rationale for administering it to a client in hepatic coma. Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted.
Question 3 of 5
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
Question 4 of 5
Discharge teaching for the client who has a total gastrectomy should include which of the following?
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
Question 5 of 5
A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:
Correct Answer: B
Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.