NCLEX-RN
NCLEX RN Nursing Exam Questions
Extract:
Question 1 of 5
During the assessment, the nurse observes a client scratching his skin. He has been admitted to rule out Laennec's cirrhosis of the liver. The nurse knows the pruritus is directly related to:
Correct Answer: B
Rationale: A loss in the phagocytic activity of the Kupffer cells occurs with cirrhosis of the liver, which increases the susceptibility to infections. The faulty processing of bilirubin produces bile salts, which are irritating to the skin. The detoxification of drugs is impaired with cirrhosis of the liver. Collateral circulation develops due to portal hypertension. This is manifest through the development of esophageal varices, hemorrhoids, and caput medusae.
Question 2 of 5
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.
Question 3 of 5
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order.
To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
Question 4 of 5
The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
Correct Answer: A
Rationale: Transphenoidal hypophysectomy can disrupt pituitary function, affecting glucose regulation. Monitoring blood sugar is critical to detect hypo- or hyperglycemia. Suctioning, positioning, or coughing is not routine.
Question 5 of 5
A client with a history of ulcerative colitis is admitted with complaints of bloody diarrhea. The nurse should give priority to:
Correct Answer: A
Rationale: Bloody diarrhea in ulcerative colitis can cause significant fluid and electrolyte loss, so monitoring for dehydration is the priority.