NCLEX-RN
NCLEX-RN Exam Practice Questions
Extract:
Question 1 of 5
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?
Correct Answer: A
Rationale: High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C,
D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.
Question 2 of 5
While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 120, respirations 36. The nurse's initial action should be to:
Correct Answer: A
Rationale: The vital signs indicate a wide pulse pressure (140/40), tachycardia (pulse 120), and tachypnea (respirations 36), suggesting possible cardiovascular or respiratory distress. The nurse should report these findings to the physician immediately for further evaluation, as they may indicate a serious condition like heart failure or shock.
Question 3 of 5
A client has ataxia following a cerebral vascular accident. The nurse should:
Correct Answer: A
Rationale: Ataxia post-stroke causes unsteady gait, increasing fall risk. Supervising ambulation ensures safety. Intake/output, speech therapy, and writing aids are unrelated to ataxia.
Question 4 of 5
A client in labor has an order for Demerol (meperidine) 75 mg. IM to be administered 10 minutes before delivery. The nurse should:
Correct Answer: B
Rationale: Meperidine given close to delivery can cause neonatal respiratory depression due to its sedative effects crossing the placenta. The nurse should question the timing of the order.
Question 5 of 5
The nurse is performing an admission assessment on a client with a history of glaucoma. Which medication is the client most likely taking?
Correct Answer: B
Rationale: Timolol, a beta-blocker eye drop, is commonly used to reduce intraocular pressure in glaucoma. Lasix, Norvasc, and Zestril treat other conditions (edema, hypertension).